Access to burn care in low-and middle-income countries: An assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

Burn injuries and acute burn management in the rural areas in northern Bangladesh - A household survey

INTRODUCTION

Burn injuries pose a significant public health challenge, especially in low- and middle-income countries (LMICs). In Bangladesh, burn injuries are prevalent and often result in severe disability or death. However, knowledge regarding the causes of burn injuries, acute burn management, and barriers to seeking burn care in the riverine areas of northern Bangladesh is limited.

METHODS

We conducted a questionnaire-based study in eight subunits and five selected districts in northern Bangladesh to determine the prevalence, causes, and management of burn injuries in these areas. A total of 210 individuals from different households were interviewed, which represented a population of 1020 persons.

RESULTS

Among the respondents, 55% reported that at least one member of their household suffered from a burn injury in the past. The most common causes of burn injuries were open fire (41%) and hot fluids (30%). More than 40% of burns were not rinsed with water directly after sustaining the injury. Additionally, almost 30% of respondents did not seek medical care immediately after the injury, with financial constraints being the most commonly cited reason.

DISCUSSION

We found a low rate of adequate cooling and seeking medical care. The need for basic knowledge on prevention and treatment of burn injuries and improved access to affordable health care services in the region is high.

Global perspectives on risk factors for major joint burn contractures: A literature review

Contractures are a frequent consequence of burn injuries, yet our knowledge of associated risk factors is limited. This paper provides an extensive review of relevant literature from both High-Income Countries (HICs) and Low-Middle Income Countries (LMICs). Ninety-four papers (up to June 2019) and eight subsequent publications (up to March 2022) were included, 76% of which were from HICs. The majority of publications were either descriptive studies (4 from HICs, 9 from LMICs) or papers citing putative risk factors (37 from HICs, 10 from LMICs). Seventeen publications (all from HICs) reported on the effects of individual non-surgical therapeutic interventions, often with conflicting results. Two published systematic reviews emphasised the poor quality of evidence available. Only fifteen studies (3 from LMICs) examined potential contracture risk factors with statistical comparisons of outcomes; significant findings from these included demographic, burn, comorbidities, and treatment risk factors. LMIC papers included socioeconomic and healthcare system factors as potential risks for contracture; these were rarely considered in HIC publications. Methodological issues identified from this review of literature included differences in contracture definitions, populations studied, standards of care, joints included and the timing and nature of contracture assessments.This review is the first to collate existing knowledge on risk factors for burn contractures from both HIC and LMIC settings, revealing a surprising lack of robust evidence for many accepted risk factors. In LMICs, where burns are particularly common, universal health provision is lacking and specialist burn care is both scarce and difficult to access; consequently, socioeconomic factors may have more immediate impact on contracture outcomes than specific burn treatments or therapies. Much more work is indicated to fully understand the relative impacts of risk factors in different settings so that context-appropriate contracture prevention strategies can be developed.

Working Towards Holistic Scar Assessment and Improved Shared Decision Making in Global Burn Care

Cutaneous burn scars impact various aspects of life. Scar treatment is mainly evaluated on scar characteristics. Consensus is needed on which other outcomes to capture, ensuring they are relevant to patients, clinicians, and researchers. The aim of this study was to identify, discuss and analyze outcomes related to cutaneous burn scarring, incorporating the voice of patients and views of healthcare professionals. For this, a Delphi process consisting of two survey rounds and a consensus meeting was initiated. Burn scar-related outcomes were identified from an existing comprehensive list of 100 outcomes by an international panel of patients, healthcare professionals and researchers. Fifty-nine outcomes were identified from the Delphi process as related to scarring (≥60% votes). Outcomes less impactful in relation to scar outcomes included psychosocial issues, sense of normality, understanding of treatment, costs and systemic issues. To represent a holistic assessment of outcomes related to cutaneous burn scarring, this Delphi process established a battery of outcomes currently included in scar quality assessment tools, and an expanded set of less frequently considered outcomes. Future work in this area must include the patient voice from developing countries. This is essential to identify globally applicable outcomes related to scarring.

The health workforce conundrum for burn care in Uttar Pradesh, India: a qualitative exploration

Delivering specialised care for major burns requires a multidisciplinary health workforce. While health systems 'hardware' issues, such as shortages of the healthcare workforce and training gaps in burn care are widely acknowledged, there is limited evidence around the systems 'software' aspects, such as interest, power dynamics, and relationships that impact the healthcare workforce performance. This study explored challenges faced by the health workforce in burn care to identify issues affecting their performance. Qualitative in-depth interviews were conducted with a purposively selected sample (n = 31, 18 women and 13 men) of various cadres of the burn care health workforce in Uttar Pradesh, India. Inductive coding and thematic analysis identified three major themes. First, the dynamics within the multidisciplinary team where complex relations, power and normative hierarchy hampered performance. Second, the dynamics between health workers and patients due to the clinical and emotional challenges of dealing with burn injuries and multitasking. Third, dynamics between specialised burn units and broader health systems are narrated in challenges due to inadequate first response and delayed referral from primary care facilities. These findings indicate that burn care health workers in India face multiple challenges that need systemic intervention with a multipronged human resource for health framework.

Food Security as a Predictor of Global Pediatric Postburn Mortality

Food security (FS) is defined as access to sufficient and nutritious food. Children, especially those in low- and middle- income countries (LMICs), are disproportionately affected by low FS. We hypothesized high FS would be predictive of decreased pediatric postburn mortality in LMICs. Publicly-available, deidentified datasets were obtained from the World Health Organization's Global Burn Registry (GBR) and Economist Intelligence Unit's Global FS Index (GFSI). The GFSI calculates FS scores annually from intergovernmental organization data reviewed by a panel of experts. FS scores are reported on a 0 to 100 scale with 100 indicating the highest FS. Patients aged 0 to 19 yr were included; after linking GBR and GFSI datasets, countries with <100 burn patients were excluded. Data were analyzed with descriptive statistics and bivariate analyses. Multiple logistic regression controlling for confounders was used to quantify associations between mortality and FS score. Significance was set at P < 0.05. From 2016 to 2020, there were 2,246 cases including 259 deaths (11.5%) over nine countries. Those who died had a higher median age (7 [IQR 2, 15] vs 3 [2, 6] years, P < 0.001), higher proportion of females (48.6% vs 42.0%, P =0.048), and lower median FS score (55.7 [IQR 45.3, 58.2] vs 59.8 [IQR 46.7, 65.7], P < 0.001). Increasing FS score was associated with decreased odds of postburn mortality [multivariable odds ratio 0.78 (95% confidence interval 0.73 to 0.83), P < 0.001]. With the association between FS and mortality, international efforts to increase FS in LMICs may help improve pediatric burn patient survival.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review

OBJECTIVE

A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region.

METHODS

We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council.

RESULTS

We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients.

CONCLUSIONS

Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA.

PROTOCOL REGISTRATION

PROSPERO CRD42021274830.