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Chao TE, Chu K, Hardcastle TC, Steyn E, Gaarder C, Hsee L, Otomo Y, Vega-Rivera F, Coimbra R, Staudenmayer K. Trauma care and its financing around the world. J Trauma Acute Care Surg 2024:01586154-990000000-00807. [PMID: 39330943 DOI: 10.1097/ta.0000000000004448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
ABSTRACT Worldwide, one billion people sustain trauma, and 5 million people will die every year from their injuries. Countries must build trauma systems to effectively address this high-burden disease, but efforts are often challenged by financial constraints. Understanding mechanisms for trauma funding internationally can help to identify opportunities to address the burden of injuries. Trauma leaders from around the world contributed summaries around how trauma is managed across their respective continents. These were aggregated to create a comparison of worldwide trauma systems of care. The burden of injuries is high across the world's inhabited continents, but trauma systems remain underfunded worldwide and, as a result, are overall underdeveloped and do not rise to the levels required given the burden of disease. Some countries in Africa and Asia have invested in financing mechanisms such as road accident funds or trauma-specific funding. In Latin America, active surgeon involvement in accident prevention advocacy has made meaningful impact. All continents show progress in trauma system maturation. This article describes how different regions of the world organize and commit to trauma care financially. Overall, while trauma tends to be underfunded, there is evidence of change in many regions and good examples of what can happen when a country invests in building trauma systems. LEVEL OF EVIDENCE Expert Opinions; Level VII.
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Affiliation(s)
- Tiffany E Chao
- From the Santa Clara Valley Medical Center (T.E.C.), San Jose, California; Department of Surgery (T.E.C., K.S.), Stanford University, Palo Alto, California; Centre for Global Surgery (T.E.C., K.C.), Stellenbosch University, Cape Town, South Africa; Department of Surgery (K.C.), University of Botswana, Gaborone, Botswana; Trauma and Burns (T.C.H.), Inkosi Albert Luthuli Central Hospital; Department of Surgery (T.C.H.), University of KwaZulu-Natal, Durban, South Africa; Division of Surgery (E.S.), Stellenbosch University, Cape Town, South Africa; Department of Traumatology (C.G.), Oslo University Hospital Ulleval; Institute of Clinical Medicine (C.G.), University of Oslo, Norway; Department of Surgery (L.H.), Auckland City Hospital, Auckland, New Zealand; National Hospital Organization Disaster Medical Center (Y.O.), Tokyo, Japan; Department of Surgery (F.V.-R.), Hospital Angeles Lomas, Huixquilucan, Mexico; and Department of Surgery (R.C.), Loma Linda University School of Medicine, Loma Linda, California
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Whitaker J, Njawala T, Nyirenda V, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard R, Leather AJM, Davies J. Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff survey. PLoS One 2024; 19:e0308525. [PMID: 39264901 PMCID: PMC11392338 DOI: 10.1371/journal.pone.0308525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 07/25/2024] [Indexed: 09/14/2024] Open
Abstract
INTRODUCTION The burden of injuries globally and in Malawi is substantial. Optimising both access to, and quality of, care in health systems requires attention. We aimed to establish how health facility staff in Karonga, Malawi, perceive barriers to seeking (delay 1), reaching (delay 2) and receiving (delay 3) injury care. METHOD We conducted a cross-sectional survey of health facility staff who treat patients with injuries in all health facilities serving the Karonga Demographic Surveillance Site population. The primary outcome was participant perceptions of the importance of delays 1 to 3 following injury. Secondary outcomes were the barriers within each of these delays considered most important and which were considered the most important across all delays stages. RESULTS 228 staff completed the survey: 36.8% (84/228) were female and 61.4% (140/228) reported being involved in caring for an injured person at least weekly. Delay 3 was most frequently considered the most important delay 35.1% (80/228), with 19.3% (44/228) and 16.6% (38/228) reporting delays 1 and 2 as the most important respectively; 28.9% (66/228) of respondents either did not know or answer. For delay 1 the barrier, "the perceived financial costs associated with seeking care are too great", was considered most important. For delay 2, the barrier "lack of timely affordable emergency transport (formal or informal)" was considered most important. For delay 3, the barrier, "lack of reliably available necessary physical resources (infrastructure, equipment and consumable material)" was considered most important. When considering the most important overall barrier across all delays, the delay 3 barrier, "lack of reliably available necessary physical resources" received the most nominations (41.7% [95/228]). CONCLUSIONS Given the awareness of health facility staff of the issues facing their patients, these findings should assist in informing health system planning.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Taniel Njawala
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Vitumbeku Nyirenda
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
- School of Medicine & Oral Health, Department of Pathology, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Andrew J M Leather
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Frankiewicz P, Sawe Y, Sakita F, Mmbaga BT, Staton C, Joiner AP, Smith ER. Financial toxicity and acute injury in the Kilimanjaro region: An application of the Three Delays Model. PLoS One 2024; 19:e0308539. [PMID: 39213278 PMCID: PMC11364231 DOI: 10.1371/journal.pone.0308539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 07/25/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Trauma and injury present a significant global burden-one that is exacerbated in low- and middle-income settings like Tanzania. Our study aimed to describe the landscape of acute injury care and financial toxicity in the Kilimanjaro region by leveraging the Three Delays Model. METHODS This cross-sectional study used an ongoing injury registry and financial questionnaires collected at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania from December 2022 until March 2023. Financial toxicity measures included catastrophic expenditure and impoverishment, in accordance with World Health Organization standards. Descriptive analysis was also performed. FINDINGS Most acute injury patients that presented to the KCMC Emergency Department experienced financial toxicity due to their out-of-pocket (OOP) hospital expenses (catastrophic health expenditure, CHE: 62.8%; impoverishment, IMP: 85.9%). Households within our same which experienced financial toxicity had more dependents (CHE: 18.4%; IMP: 17.9% with ≥6 dependents) and lower median monthly adult-equivalent incomes (CHE: 2.53 times smaller than non-CHE; IMP: 4.27 times smaller than non-IMP). Individuals experiencing financial toxicity also underwent more facility transfers with a higher surgical burden. INTERPRETATION Delay 1 (decision to seek care) and Delay 2 (reaching appropriate care facility) could be significant factors for those who will experience financial toxicity. In the Tanzanian healthcare system where national health insurance is present, systematic expansions are indicated to target those who are at higher risk for financial toxicity including those who live in rural areas, experience unemployment, and have many dependents.
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Affiliation(s)
- Parker Frankiewicz
- Global Emergency Medicine Innovation and Implementation Research Center, Duke Global Health Institute, Durham, NC, United States of America
| | - Yvonne Sawe
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Catherine Staton
- Global Emergency Medicine Innovation and Implementation Research Center, Duke Global Health Institute, Durham, NC, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Anjni P. Joiner
- Global Emergency Medicine Innovation and Implementation Research Center, Duke Global Health Institute, Durham, NC, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Emily R. Smith
- Global Emergency Medicine Innovation and Implementation Research Center, Duke Global Health Institute, Durham, NC, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
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Klappenbach R, Monteverde E, Santero M, Bosque L, Neira J. Budget impact analysis of implementing trauma registries in Argentina. Injury 2024; 55:111781. [PMID: 39154489 DOI: 10.1016/j.injury.2024.111781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/03/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION In high-income countries, quality improvement interventions and research are usually guided by trauma registries. In low- and middle-income countries, the implementation of trauma registries has been limited mainly for cost reasons. OBJECTIVE To analyze the budgetary impact of the implementation of trauma registries in Argentina. METHODS We estimated direct costs of implementing trauma registries in public hospitals located in cities with a population over 50,000 inhabitants. In large urban areas, we selected hospitals by estimating a minimum volume of 240 severe trauma admissions/year and using the NBATS-2 instrument with geolocation techniques. We estimated costs based on a micro-costing approach of a trauma registry developed by Fundación Trauma. Scenario analysis was carried out restricting the population to hospitals from bigger cities and/or with higher concentration of trauma patients' care. For the high budget impact threshold, we used the total health spending estimation, and alternatively the health spending of the public sector. RESULTS For the base case, 139 hospitals from 104 cities were included, comprising 175,605 injury-related discharges and 13,707 severely injured patients/year. The average cost for the initial three years was USD 3,753,085 (21.4 USD/per patient), falling below the high budget impact thresholds. The scenarios analysis showed a significantly costs reduction. CONCLUSIONS The implementation of trauma registries in Argentina would be affordable, and in consequence, it would improve the coordination, management and quality of care for this great public health issue.
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Affiliation(s)
| | | | - Marilina Santero
- Fundación Trauma, Tacuarí 352, (C1071AAH), Buenos Aires, Argentina; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Laura Bosque
- Fundación Trauma, Tacuarí 352, (C1071AAH), Buenos Aires, Argentina
| | - Jorge Neira
- Fundación Trauma, Tacuarí 352, (C1071AAH), Buenos Aires, Argentina
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Nazir A, Shore EM, Keown-Stoneman C, Grantcharov T, Nolan B. Enhancing patient safety in trauma: Understanding adverse events, assessment tools, and the role of trauma video review. Am J Surg 2024; 234:74-79. [PMID: 38719680 DOI: 10.1016/j.amjsurg.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/11/2024] [Accepted: 04/26/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVES This study aimed to investigate adverse events (AEs) in trauma resuscitation, evaluate contributing factors, and assess methods, such as trauma video review (TVR), to mitigate AEs. BACKGROUND Trauma remains a leading cause of global mortality and morbidity, necessitating effective trauma care. Despite progress, AEs during trauma resuscitation persist, impacting patient outcomes and the healthcare system. Identifying and analyzing AEs and their determinants are crucial for improving trauma care. METHODS This narrative review explored the definition, identification, and assessment of AEs associated with trauma resuscitation within the trauma system. It includes various studies and assessment tools such as STAT Taxonomy and T-NOTECHs. Additionally, it assessed the role of TVR in detecting AEs and strategies to enhance patient safety. CONCLUSION Integrated with standardized tools, TVR shows promise for identifying AEs. Challenges include ensuring reporting consistency and integrating approaches into existing protocols. Future research should prioritize linking trauma team performance to patient outcomes, and develop sustainable TVR programs to enhance patient safety.
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Affiliation(s)
- Anisa Nazir
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
| | - Eliane M Shore
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON, Canada
| | - Charles Keown-Stoneman
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Teodor Grantcharov
- Department of Surgery, Clinical Excellence Research Center, Stanford University, USA
| | - Brodie Nolan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Emergency Medicine, St. Michael's Hospital Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada
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Yost MT, Blair KJ, Poppens M, Mallahi M, Dang LE, Oke R, Carvalho M, Etoundi-Mballa GA, Hubbard A, Kouo Ngamby M, Maqungo S, Chironga K, McCoy SI, Chichom-Mefire A, Juillard C, Maswime S, Dissak Delon FN. Who seeks care after intimate partner violence in Cameroon? sociodemographic differences between a hospital and population sample of women. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003408. [PMID: 39028719 PMCID: PMC11259300 DOI: 10.1371/journal.pgph.0003408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 06/03/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Little is known regarding health care seeking behaviors of women in sub-Saharan Africa, specifically Cameroon, who experience violence. The proportion of women who experienced violence enrolled in the Cameroon Trauma Registry (CTR) is lower than expected. METHODS We concatenated the databases from the October 2017-December 2020 CTR and 2018 Cameroon Demographic and Health Survey (DHS) into a singular database for cross-sectional study. Continuous and categorical variables were compared with Wilcoxon rank-sum and Fisher's exact test. Multivariable logistic regression examined associations between demographic factors and women belonging to the DHS or CTR cohort. We performed additional classification tree and random forest variable importance analyses. RESULTS 276 women (13%) in the CTR and 197 (13.1%) of women in the DHS endorsed violence from any perpetrator. A larger percentage of women in the DHS reported violence from an intimate partner (71.6% vs. 42.7%, p<0.001). CTR women who experienced IPV demonstrated greater university-level education (13.6% vs. 5.0%, p<0.001) and use of liquid petroleum gas (LPG) cooking fuel (64.4% vs. 41.1%, p<0.001). DHS women who experienced IPV reported greater ownership of agricultural land (29.8% vs. 9.3%, p<0.001). On regression, women who experienced IPV using LPG cooking fuel (aOR 2.55, p = 0.002) had greater odds of belonging to the CTR cohort while women who owned agricultural land (aOR 0.34, p = 0.007) had lower odds of presenting to hospital care. Classification tree variable observation demonstrated that LPG cooking fuel predicted a CTR woman who experienced IPV while ownership of agricultural land predicted a DHS woman who experienced IPV. CONCLUSION Women who experienced violence presenting for hospital care have characteristics associated with higher SES and are less likely to demonstrate factors associated with residence in a rural setting compared to the general population of women experiencing violence.
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Affiliation(s)
- Mark T. Yost
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | - Kevin J. Blair
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | - McKayla Poppens
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | - Michelle Mallahi
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | - Lauren Eyler Dang
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Rasheedat Oke
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | - Melissa Carvalho
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | | | - Alan Hubbard
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | | | - Sithombo Maqungo
- Department of Surgery, Division of Global Surgery, University of Cape Town, Cape Town, South Africa
- Division of Orthopaedic Surgery, Orthopaedic Trauma Service, University of Cape Town, Cape Town, South Africa
| | - Kudzai Chironga
- Department of Surgery, Division of Global Surgery, University of Cape Town, Cape Town, South Africa
- Division of Orthopaedic Surgery, Orthopaedic Trauma Service, University of Cape Town, Cape Town, South Africa
| | - Sandra I. McCoy
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | | | - Catherine Juillard
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, United States of America
| | - Salome Maswime
- Department of Surgery, Division of Global Surgery, University of Cape Town, Cape Town, South Africa
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Kennedy C, Ignatowicz A, Odland ML, Abdul-Latif AM, Belli A, Howard A, Whitaker J, Chu KM, Ferreira K, Owolabi EO, Nyamathe S, Tabiri S, Ofori B, Pognaa Kunfah SM, Yakubu M, Bekele A, Alyande B, Nzasabimana P, Byiringiro JC, Davies J. Commonalities and differences in injured patient experiences of accessing and receiving quality injury care: a qualitative study in three sub-Saharan African countries. BMJ Open 2024; 14:e082098. [PMID: 38955369 PMCID: PMC11218010 DOI: 10.1136/bmjopen-2023-082098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVES To understand commonalities and differences in injured patient experiences of accessing and receiving quality injury care across three lower-income and middle-income countries. DESIGN A qualitative interview study. The interviews were audiorecorded, transcribed and thematically analysed. SETTING Urban and rural settings in Ghana, South Africa and Rwanda. PARTICIPANTS 59 patients with musculoskeletal injuries. RESULTS We found five common barriers and six common facilitators to injured patient experiences of accessing and receiving high-quality injury care. The barriers encompassed issues such as service and treatment availability, transportation challenges, apathetic care, individual financial scarcity and inadequate health insurance coverage, alongside low health literacy and information provision. Facilitators included effective information giving and informed consent practices, access to health insurance, improved health literacy, empathetic and responsive care, comprehensive multidisciplinary management and discharge planning, as well as both informal and formal transportation options including ambulance services. These barriers and facilitators were prevalent and shared across at least two countries but demonstrated intercountry and intracountry (between urbanity and rurality) variation in thematic frequency. CONCLUSION There are universal factors influencing patient experiences of accessing and receiving care, independent of the context or healthcare system. It is important to recognise and understand these barriers and facilitators to inform policy decisions and develop transferable interventions aimed at enhancing the quality of injury care in sub-Saharan African nations.
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Affiliation(s)
- Ciaran Kennedy
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, St. Olavs University Hospital, Trondheim, Norway
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Abdul-Malik Abdul-Latif
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Volta Regional Health Directorate, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Antonio Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Anthony Howard
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Centre, University of Oxford, Headington, UK
| | - John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Kathryn M Chu
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
- Department of Surgery, University of Botswana, Gaborone, Botswana
| | - Karen Ferreira
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Eyitayo O Owolabi
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Samukelisiwe Nyamathe
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Stephen Tabiri
- Ghana HUB of NIHR Global Surgery, Tamale, Ghana
- Department of Public Health, Tamale Teaching Hospital, Tamale, Ghana
- Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | | | | | - Mustapha Yakubu
- Department of Public Health, Tamale Teaching Hospital, Tamale, Ghana
- School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Barnabas Alyande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jean-Claude Byiringiro
- University of Rwanda, Kigali, Rwanda
- Department of Surgery, University Teaching Hospital, Kigali, Rwanda
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise. BMJ Open 2024; 14:e085064. [PMID: 38925682 PMCID: PMC11202735 DOI: 10.1136/bmjopen-2024-085064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement. DESIGN Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations. SETTING The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients. PARTICIPANTS 24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites. RESULTS Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making. DISCUSSION We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.
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Agoubi LL, Issaka A, Sulaiman S, Gyedu A. Experiences of injured patients referred to higher levels of care after initial assessment and management at non-tertiary hospitals in Ghana. Afr J Emerg Med 2024; 14:109-114. [PMID: 38756827 PMCID: PMC11096712 DOI: 10.1016/j.afjem.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/02/2024] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Background The experiences of trauma patients referred from Ghanaian non-tertiary hospitals for definitive care at higher levels is not well-known. Understanding the motivations of injured patients who do not attend their referral for definitive management may inform interventions to improve injury outcomes. Methods This study is a follow-up survey of participants of a larger study involving initial management of injured patients presenting to 8 non-tertiary hospitals in Ghana from October 2020 to March 2022. Injured patients referred to higher levels of care were surveyed by phone using a structured questionnaire and patients who could not be reached were excluded. The main outcome was referral non-attendance and differences between patients who attended the referral and those who did not were determined with chi squared tests. Variables with intergroup differences were included in a multivariable logistic regression. Open-ended survey responses were analyzed using thematic content analysis. Results Of 335 referred patients surveyed, 17 % did not attend the referral. Factors associated with referral non-attendance included being male (Adjusted odds ratio (AOR)=2.70, p = 0.013), sustaining a fracture (AOR=2.83, p = 0.003), and having less severe injury (AOR 2.84, p = 0.017). Primary drivers of referral non-attendance included financial problems (59 %), family influence (45 %), and lack of transportation (20 %). The majority of patients (77 %) not attending the referral sought treatment from traditional healers, citing lower cost, faster service, and a perception of equivalent outcomes. Reported facilitators of referral attendance included positive hospital staff experiences and treatment while barriers included higher hospital costs, lack of bed space, and poor interhospital communication. Conclusions An important proportion of injured patients in Ghana do not attend referrals for definitive management, with many seeking care from traditional healers. Our study identified possible targets for interventions aimed at maintaining the continuum of hospital-based care for injured patients in order to improve outcomes.
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Affiliation(s)
- Lauren L. Agoubi
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Adamu Issaka
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Sakinah Sulaiman
- University of Buckingham Medical School, Buckingham, United Kingdom
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Agarwal A, Surti V, Terry MA. Recommendations to improve maternal mortality among Rohingya women in Bangladeshi refugee camps. Health Care Women Int 2024:1-12. [PMID: 38743403 DOI: 10.1080/07399332.2024.2349820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
Despite current humanitarian efforts, The Rohingya in Bangladesh's refugee camps have among the highest maternal mortality worldwide. The authors review maternal mortality within Rohingya refugee populations in Bangladesh, citing the camp conditions and cultural norms that affect the Maternal Mortality Ratio (MMR). Next, the authors review current humanitarian efforts made by the UNFPA toward improving reproductive health. Finally, the authors recommend a three-pronged approach to reducing maternal mortality among the Rohingya in Bangladeshi refugee camps. We suggest using Maternity Waiting Homes, Mama Rickshaws, and Traditional Birth Attendants to improve maternal health. These solutions address the three-delays model and place ownership into the community. Ultimately, the authors address a much-needed gap in the literature addressing Rohingya maternal mortality.
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Affiliation(s)
| | - Vidya Surti
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Whitaker J, Edem I, Amoah AS, Dube A, D'Ambruoso L, Rickard RF, Leather AJM, Davies J. Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data. BMJ Open 2024; 14:e081652. [PMID: 38684258 PMCID: PMC11086451 DOI: 10.1136/bmjopen-2023-081652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care. DESIGN Retrospective analysis of existing VA data routinely collected by a demographic surveillance site. SETTING Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi. PARTICIPANTS Fatally injured members of the HDSS. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system. RESULTS Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49). CONCLUSIONS VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Idara Edem
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, USA
- Michigan State University, East Lansing, Michigan, USA
| | - Abena S Amoah
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health, National Health Service (NHS) Grampian, Grampian, Scotland
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andy J M Leather
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Davies J, Chu K, Tabiri S, Byiringiro JC, Bekele A, Razzak J, D’Ambruoso L, Ignatowicz A, Bojke L, Nkonki L, Laurenzi C, Sitch A, Bagahirwa I, Belli A, Sam NB, Amberbir A, Whitaker J, Ndangurura D, Ghalichi L, MacQuene T, Tshabalala N, Fikadu Berhe D, Nepomuscene NJ, Agbeko AE, Sarfo-Antwi F, Babar Chand Z, Wajidali Z, Sahibjan F, Atiq H, Mali Y, Tshabalala Z, Khalfe F, Nodo O, Umwali G, Twizeyimana E, Mugisha N, Munyura NO, Nakure S, Ishimwe SMC, Nzasabimana P, Dramani A, Acquaye J, Tanweer A. Equitable access to quality injury care; Equi-Injury project protocol for prioritizing interventions in four low- or middle-income countries: a mixed method study. BMC Health Serv Res 2024; 24:429. [PMID: 38576004 PMCID: PMC10996087 DOI: 10.1186/s12913-024-10668-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/31/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Equitable access to quality care after injury is an essential step for improved health outcomes in low- and middle-income countries (LMICs). We introduce the Equi-Injury project, in which we will use integrated frameworks to understand how to improve equitable access to quality care after injury in four LMICs: Ghana, Pakistan, Rwanda and South Africa. METHODS This project has 5 work packages (WPs) as well as essential cross-cutting pillars of community engagement, capacity building and cross-country learning. In WP1, we will identify needs, barriers, and facilitators to impactful stakeholder engagement in developing and prioritising policy solutions. In WP2, we will collect data on patient care and outcomes after injuries. In WP3, we will develop an injury pathway model to understand which elements in the pathway of injury response, care and treatment have the biggest impact on health and economic outcomes. In WP4, we will work with stakeholders to gain consensus on solutions to address identified issues; these solutions will be implemented and tested in future research. In WP5, in order to ascertain where learning is transferable across contexts, we will identify which outcomes are shared across countries. The study has received approval from ethical review boards (ERBs) of all partner countries in South Africa, Rwanda, Ghana, Pakistan and the University of Birmingham. DISCUSSION This health system evaluation project aims to provide a deeper understanding of injury care and develop evidence-based interventions within and across partner countries in four diverse LMICs. Strong partnership with multiple stakeholders will facilitate utilisation of the results for the co-development of sustainable interventions.
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Negussie H, Getachew M, Deneke A, Tadesse A, Abdella A, Prince M, Leather A, Hanlon C, Willott C, Mayston R. "Problems you can live with" versus emergencies: how community members in rural Ethiopia contend with conditions requiring surgery. BMC Health Serv Res 2024; 24:214. [PMID: 38365723 PMCID: PMC10874059 DOI: 10.1186/s12913-024-10620-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/18/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND 98% of people with surgical conditions living in low- and middle-income countries (LMICs) do not receive safe, timely and affordable surgical and anesthesia care. Research exploring barriers to receiving care has tended to be narrow in focus, often facility-based and ignoring the community beliefs, experiences and behaviours that will be an essential component of closing the gap in surgical care. Using qualitative methods, we captured diverse community perspectives in rural Ethiopia: exploring beliefs, perceptions, knowledge and experiences related to surgical conditions, with the overall aim of (re)constructing explanatory models. METHODS Our study was nested within a community-based survey of surgical conditions conducted in the Butajira Health and Demographic Surveillance Site, southern Ethiopia, and a follow-up study of people accessing surgical care in two local hospitals. We carried out 24 semi-structured interviews. Participants were community members who needed but did/did not access surgical care, community-based healthcare workers and traditional bone-setters. Interviews were conducted in Amharic, audio-recorded, transcribed, and translated into English. We initially carried out thematic analysis and we recognized that emerging themes were aligned with Kleinman's explanatory models framework and decided to use this to guide the final stages of analysis. RESULTS We found that community members primarily understood surgical conditions according to severity. We identified two categories: conditions you could live with and those which required urgent care, with the latter indicating a clear and direct path to surgical care whilst the former was associated with a longer, more complex and experimental pattern of help-seeking. Fear of surgery and poverty disrupted help-seeking, whilst community narratives based on individual experiences fed into the body of knowledge people used to inform decisions about care. CONCLUSIONS We found explanatory models to be flexible, responsive to new evidence about what might work best in the context of limited community resources. Our findings have important implications for future research and policy, suggesting that community-level barriers have the potential to be responsive to carefully designed interventions which take account of local knowledge and beliefs.
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Affiliation(s)
- Hanna Negussie
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.
| | - Medhanit Getachew
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Andualem Deneke
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amezene Tadesse
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed Abdella
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Martin Prince
- King's Global Health Institute, King's College London, London, UK
| | - Andrew Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Charlotte Hanlon
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT- Africa), College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Chris Willott
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Rosie Mayston
- Global Health & Social Medicine, King's College London, London, UK
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Whitaker J, Amoah AS, Dube A, Rickard R, Leather AJM, Davies J. Access to quality care after injury in Northern Malawi: results of a household survey. BMC Health Serv Res 2024; 24:131. [PMID: 38268016 PMCID: PMC10809521 DOI: 10.1186/s12913-023-10521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury. METHODS We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked. RESULTS Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142). CONCLUSION Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (Formerly Karonga Prevention Study), Chilumba, Malawi
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (Formerly Karonga Prevention Study), Chilumba, Malawi
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Whitaker J, Edem I, Togun E, Amoah AS, Dube A, Chirwa L, Munthali B, Brunelli G, Van Boeckel T, Rickard R, Leather AJM, Davies J. Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi. PLoS Med 2024; 21:e1004344. [PMID: 38252654 PMCID: PMC10843098 DOI: 10.1371/journal.pmed.1004344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/05/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings. METHODS AND FINDINGS To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework. CONCLUSIONS By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Idara Edem
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | - Ella Togun
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Abena S. Amoah
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
- School of Medicine & Oral Health, Department of Pathology, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
| | - Giulia Brunelli
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
| | - Thomas Van Boeckel
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
- Center for Disease Dynamics Economics and Policy, Washington, DC, United States of America
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Andrew JM Leather
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Dresch Vascouto H, Melo HM, de Oliveira Thais MER, Schwarzbold ML, Lin K, Pizzol FD, Kupek E, Walz R. Cognitive Performance of Brazilian Patients With Favorable Outcomes After Severe Traumatic Brain Injury: A Prospective Study. Am J Phys Med Rehabil 2023; 102:1070-1075. [PMID: 37204939 DOI: 10.1097/phm.0000000000002279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the cognitive performance of patients with favorable outcomes, determined by the Glasgow Outcome Scale, 1 yr after hospital discharge due to severe traumatic brain injury. DESIGN This was a prospective case-control study. From 163 consecutive adult patients with severe traumatic brain injury included in the study, 73 patients had a favorable outcome (Glasgow Outcome Scale score of 4 or 5) 1 yr after hospital discharge and were eligible for the cognitive evaluation, of which 28 completed the evaluations. The latter were compared with 44 healthy controls. RESULTS The average loss of cognitive performance among participants with traumatic brain injury varied between 13.35% and 43.49% compared with the control group. Between 21.4% and 32% of the patients performed below the 10th percentile on three language tests and two verbal memory tests, whereas 39% to 50% performed below this threshold on one language test and three memory tests. Longer hospital stay, older age, and lower education were the most important predictors of worse cognitive performance. CONCLUSION One year after a severe traumatic brain injury, a significant proportion of Brazilian patients with the favorable outcome determined by Glasgow Outcome Scale still showed significant cognitive impairment in verbal memory and language domains.
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Affiliation(s)
- Helena Dresch Vascouto
- From the Center for Applied Neuroscience (CeNAp), Department of Clinical Medicine, University Hospital-UFSC (HU-UFSC) (HDV, HMM, MLS, KL, RW), Graduate Program in Neuroscience (HDV, HMM, MERdOT, RW), Graduate Program in Medical Sciences (MERdOT, MLS, KL, RW), Psychiatry Unit, Department of Internal Medicine, University Hospital (HU) (MLS), Neurology Unit, Department of Internal Medicine, University Hospital-UFSC (HU-UFSC) (KL, RW), and Department of Public Health (EK), Federal University of Santa Catarina (UFSC), Florianópolis/SC; and Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Santa Catarina, Brazil (FDP)
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Ali AE, Sharma S, Elebute OA, Ademuyiwa A, Mashavave NZ, Chitnis M, Abib S, Wahid FN. Trauma and sexual abuse in children-Epidemiology, challenges, management strategies and prevention in lower- and middle-income countries. Semin Pediatr Surg 2023; 32:151356. [PMID: 38041908 DOI: 10.1016/j.sempedsurg.2023.151356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
Trauma is rising as a cause of morbidity and mortality in lower- and middle-income countries (LMIC). This article describes the Epidemiology, Challenges, Management strategies and prevention of pediatric trauma in lower- and middle-income countries. The top five etiologies for non-intentional injuries leading to death are falls, road traffic injuries, burns, drowning and poisoning. The mortality rate in LMICs is twice that of High-Income Countries (HICs) irrespective of injury severity adjustment. The reasons for inadequate care include lack of facilities, transportation problems, lack of prehospital care, lack of resources and trained manpower to handle pediatric trauma. To overcome these challenges, attention to protocolized care and treatment adaptation based on resource availability is critical. Training in management of trauma helps to reduce the mortality and morbidity in pediatric polytrauma cases. There is also a need for more collaborative research to develop preventative measures to childhood trauma.
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Affiliation(s)
- Abdelbasit E Ali
- Department of Pediatric Surgery, King Saud Medical City, KSA, Associate Professor of Surgery, Faculty of Medicine, University of Khartoum, Sudan
| | - Shilpa Sharma
- MCh, PhD, ATLS Faculty, ISTPF(UK), FIAPS, MNAMS, FAMS. Professor of Pediatric Surgery, Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Olumide A Elebute
- College of Medicine, University of Lagos and Lagos University Teaching Hospital Idi Araba, Lagos, Nigeria
| | - Adesoji Ademuyiwa
- Department of Surgery, College of Medicine, University of Lagos & Honorary Consultant and Chief Pediatric Surgery Unit, Lagos University Teaching Hospital. Lagos, Nigeria
| | - Noxolo Z Mashavave
- Department of Pediatric Surgery, East London Hospital Complex, Walter Sisulu University, East London, Eastern Cape, South Africa
| | - Milind Chitnis
- Department of Pediatric Surgery, East London Hospital Complex, Walter Sisulu University, East London, Eastern Cape, South Africa
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Nzasabimana P, Ignatowicz A, Alayande BT, Abdul-Latif AM, Odland ML, Davies J, Bekele A, Byiringiro JC. Barriers to equitable access to quality trauma care in Rwanda: a qualitative study. BMJ Open 2023; 13:e075117. [PMID: 37770259 PMCID: PMC10546151 DOI: 10.1136/bmjopen-2023-075117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVES Using the 'Four Delay' framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients', caregivers' and community leaders' perspectives. DESIGN A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically. SETTING This qualitative study was conducted in Rwanda's rural Burera District, located in the Northern Province, and in Kigali City, the country's urban capital, to capture both the rural and urban population's experiences of being injured. PARTICIPANTS Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders. RESULTS Multiple barriers were identified cutting across all levels of the 'Four Delays' framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients. CONCLUSIONS Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation.
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Affiliation(s)
- Pascal Nzasabimana
- Single Project Implementation Unit, University of Rwanda, Kigali, Rwanda
| | | | - Barnabas Tobi Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Jean Claude Byiringiro
- School of Medicine and Pharmacy, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
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Odland ML, Abdul-Latif AM, Ignatowicz A, Bekele A, Chu K, Howard A, Tabiri S, Byiringiro JC, Davies J. Governance for injury care systems in Ghana, South Africa and Rwanda: development and pilot testing of an assessment tool. BMJ Open 2023; 13:e074088. [PMID: 37666564 PMCID: PMC10481730 DOI: 10.1136/bmjopen-2023-074088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/25/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVES This study aims to evaluate health systems governance for injury care in three sub-Saharan countries from policymakers' and injury care providers' perspectives. SETTING Ghana, Rwanda and South Africa. DESIGN Based on Siddiqi et al's framework for governance, we developed an online assessment tool for health system governance for injury with 37 questions covering health policy and implementation under 10 overarching principles of strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness of institutions, equity, effectiveness or efficiency, accountability, ethics and intelligence and information. A literature review was also done to support the scoring. We derived scores using two methods-investigator scores and respondent scores. PARTICIPANTS The tool was sent out to purposively selected stakeholders, including policymakers and injury care providers in Ghana, Rwanda and South Africa. Data were collected between October 2020 and February 2021. PRIMARY AND SECONDARY OUTCOMES Investigator-weighted and respondent percentage scores for health system governance for injury care. This was calculated for each country in total and per principle. RESULTS Rwanda had the highest overall investigator-weighted percentage score (70%), followed by South Africa (59%). Ghana had the lowest overall investigator score (48%). The overall results were similar for the respondent scores. Some areas, such as participation and consensus, scored high in all three countries, while other areas, such as transparency, scored very low. CONCLUSION In this multicountry governance survey, we provide insight into and evaluation of health system governance for trauma in three low- and middle-income countries (LMICs) in sub-Saharan Africa. It highlights areas of improvement that need to be prioritised, such as transparency, to meet the high burden of trauma and injuries in LMICs.
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Affiliation(s)
- Maria Lisa Odland
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
- Department of Obstetrics and Gynecology, St Olavs Hospital Trondheim University Hospital, Trondheim, Trøndelag, Norway
| | | | | | - Abebe Bekele
- University of Global Health Equity, Kigali, Gasabo, Rwanda
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Department of Surgery, University of Botswana, Gaborone, Botswana
| | - Anthony Howard
- University of Leeds, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Centre, University of Oxford, Oxford, UK
| | - Stephen Tabiri
- Ghana Hub of NIHR Global Surgery, Tamale, Northern, Ghana
- Department of Surgery, Tamale Teaching Hospital, Tamale, Northern, Ghana
| | - Jean Claude Byiringiro
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Justine Davies
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
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20
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Tefera A, Lutge EE, Moodley N, Xaba XW, Hardcastle TC, Brysiewicz P, Clarke DL. Tracking the Trauma Epidemic in KwaZulu-Natal, South Africa. World J Surg 2023; 47:1940-1945. [PMID: 37160653 PMCID: PMC10310579 DOI: 10.1007/s00268-023-07032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Trauma remains an important cause of morbidity and mortality in South Africa, but attempts to track the epidemic are often based on mortality data, or derived from individual health facilities. This project is based on the routine collection of trauma data from all public health facilities in the province of KwaZulu-Natal (KZN), between 2012 and 2022. METHODS Hospital level data on trauma over the past ten years was drawn from the district health information system (DHIS). Data relating to assaults, gunshots and motor vehicle collisions (MVCs) were recorded in the emergency rooms, whilst data on admissions are recorded in the wards and intensive care units. RESULTS There were 1,263,847 emergency room visits for assaults, gunshots and MVCs over the ten-year period and trauma admissions ranged between four and five percent of the total number of hospital admissions annually. There was a dramatic decrease in trauma presentations and admissions over 2020/2021 as a result of the COVID lockdowns. Over the entire period, intentional injury was roughly twice as frequent as non-intentional injury. Intentional trauma had an almost equal ratio of blunt assault to penetrating assault. Gunshot-related assault increased dramatically over the 2021/2022 collecting period. CONCLUSIONS The burden of trauma in KZN remains high. The unique feature of this burden is the excessively high rate of intentional trauma in the form of both blunt and penetrating mechanisms. Developing injury-prevention strategies to reduce the burden of interpersonal violence is more difficult than for unintentional trauma.
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Affiliation(s)
- Aida Tefera
- Health Services Planning, Delivery, Monitoring and Evaluation Component, KZN Department of Health, Durban, South Africa
| | - Elizabeth Eleanor Lutge
- Health Services Planning, Delivery, Monitoring and Evaluation Component, KZN Department of Health, Durban, South Africa.
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
| | - Nirvasha Moodley
- Health Services Planning, Delivery, Monitoring and Evaluation Component, KZN Department of Health, Durban, South Africa
| | - Xolani Wiseman Xaba
- Health Services Planning, Delivery, Monitoring and Evaluation Component, KZN Department of Health, Durban, South Africa
| | - Timothy Craig Hardcastle
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
- Inkosi Albert Luthuli Central Hospital, KZN Department of Health, Durban, South Africa
| | - Petra Brysiewicz
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Damian Luiz Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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21
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Open tibial shaft fractures: treatment patterns in sub-Saharan Africa. OTA Int 2023; 6:e228. [PMID: 36919118 PMCID: PMC10005832 DOI: 10.1097/oi9.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 06/18/2023]
Abstract
Objective Open tibial shaft fractures are a leading cause of disability worldwide, particularly in low and middle-income countries (LMICs). Guidelines for these injuries have been developed in many high-income countries, but treatment patterns across Africa are less well-documented. Methods A survey was distributed to orthopaedic service providers across sub-Saharan Africa. Information gathered included surgeon and practice setting demographics and treatment preferences for open tibial shaft fractures across 3 domains: initial debridement, antibiotic administration, and fracture stabilization. Responses were grouped according to country income level and were compared between LMICs and upper middle-income countries (UMICs). Results Responses from 261 survey participants from 31 countries were analyzed, with 80% of respondents practicing in LMICs. Most respondents were male practicing orthopaedic surgeons at a tertiary referral hospital. For all respondents, initial debridement occurred most frequently in the operating room (OR) within the first 24 hours, but LMIC surgeons more frequently reported delays due to equipment availability, treatment cost, and OR availability. Compared with their UMIC counterparts, LMIC surgeons less frequently confirmed tetanus vaccination status and more frequently used extended courses of postoperative antibiotics. LMIC surgeons reported lower rates of using internal fixation, particularly for high-grade and late-presenting fractures. Conclusions This study describes management characteristics of open tibial shaft fractures in sub-Saharan Africa. Notably, there were reported differences in wound management, antibiotic administration, and fracture stabilization between LMICs and UMICs. These findings suggest opportunities for standardization where evidence is available and further research where it is lacking. Level of Evidence VI-Cross-Sectional Study.
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Whitaker J, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard RF, Leather AJM, Davies J. Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi. BMJ Open 2023; 13:e070900. [PMID: 37263691 PMCID: PMC10255326 DOI: 10.1136/bmjopen-2022-070900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/21/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi. DESIGN Facilitated group process mapping workshops with summary process mapping synthesis. SETTING Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi. PARTICIPANTS Fifty-four healthcare workers from various cadres took part. RESULTS An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities). CONCLUSIONS We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Abena S Amoah
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Health Office, Karonga, Malawi
- Department of Pathology, School of Medicine & Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Boston Munthali
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
- Department of Orthopaedic Surgery, Mzuzu Central Hospital, Mzuzu, Malawi
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Mac Quene T, Smith L, Odland ML, Levine S, D'Ambruoso L, Davies J, Chu K. Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop. Glob Health Action 2022; 15:2067395. [PMID: 35730572 PMCID: PMC9225684 DOI: 10.1080/16549716.2022.2067395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. OBJECTIVE To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. METHODS A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. RESULTS Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. CONCLUSIONS This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.
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Affiliation(s)
- Tamlyn Mac Quene
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Luné Smith
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maria Lisa Odland
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Susan Levine
- Department of Anthropology, Humanities Faculty, University of Cape Town, Cape Town, South Africa
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Justine Davies
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Institute for Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Mesic A, Gyedu A, Mehta K, Goodman SK, Mock C, Quansah R, Donkor P, Stewart B. Factors Contributing to and Reducing Delays in the Provision of Adequate Care in Ghana: A Qualitative Study of Trauma Care Providers. World J Surg 2022; 46:2607-2615. [PMID: 35994075 PMCID: PMC10424506 DOI: 10.1007/s00268-022-06686-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Ghana has a large and growing burden of injury morbidity and mortality. There is a substantial unmet need for trauma surgery, highlighting a need to understand gaps in care. METHODS We conducted 8 in-depth interviews with trauma care providers (surgeons, nurses, and specialists) at a large teaching hospital to understand factors that contribute to and reduce delays in the provision of adequate trauma care for severely injured patients. The study aimed to understand whether providers thought factors differed between patients that were enrolled in the National Health Insurance Scheme (NHIS) and those that were not. Findings were presented for the third delay (provision of appropriate care) in the Three Delays Framework. RESULTS Key findings included that most factors contributing delays in the provision of adequate care were related to the costs of care, including for diagnostics, medications, and treatment for patients with and without NHIS subscription. Other notable factors included conflicts between providers, resource constraints, and poor coordination of care at the facility. Factors which reduce delays included advocacy by providers and informal processes for prioritizing critical injuries. CONCLUSION We recommend facility-level changes including increasing equity in access to trauma and elective surgery through targeted system strengthening efforts (e.g., a scheduled back-up call system for surgeons, anesthetists, other specialists, and nurses; designated operating theatres and staff for emergencies; training of staff), policy changes to simplify the insurance renewal and subscription processes, and future research on the costs and benefits of including diagnostics, medications, and common trauma services into the NHIS benefits package.
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Affiliation(s)
- Aldina Mesic
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kajal Mehta
- Department of Surgery, University of Washington, Seattle, WA, USA
| | | | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Robert Quansah
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
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Suresh K, Dixon JM, Patel C, Beaty B, Del Junco DJ, de Vries S, Lategan HJ, Steyn E, Verster J, Schauer SG, Becker TE, Cunningham C, Keenan S, Moore EE, Wallis LA, Baidwan N, Fosdick BK, Ginde AA, Bebarta VS, Mould-Millman NK. The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa. Scand J Trauma Resusc Emerg Med 2022; 30:55. [PMID: 36253865 PMCID: PMC9574798 DOI: 10.1186/s13049-022-01041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa. Methods The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure). Discussion This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system. Trial Registration: Not applicable as this study is not a clinical trial.
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Affiliation(s)
- Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Julia M Dixon
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Chandni Patel
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Brenda Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Deborah J Del Junco
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa
| | - Hendrick J Lategan
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elmin Steyn
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janette Verster
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Steven G Schauer
- U.S. Army Institute of Surgical Research, San Antonio Medical Center, San Antonio, TX, USA
| | - Tyson E Becker
- Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA
| | - Cord Cunningham
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA
| | - Sean Keenan
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Lee A Wallis
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa.,Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Navneet Baidwan
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Bailey K Fosdick
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.
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26
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Brima N, Morhason-Bello IO, Charles V, Davies J, Leather AJ. Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions. BMJ Open 2022; 12:e062616. [PMID: 36220318 PMCID: PMC9557325 DOI: 10.1136/bmjopen-2022-062616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning. DESIGN We conducted a systematic literature review and narrative synthesis. SETTING Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021. PARTICIPANTS MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched. INTERVENTION We extracted data on intervention characteristics and how the intervention was delivered and evaluated. PRIMARY AND SECONDARY OUTCOME MEASURES Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed. RESULTS Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains. CONCLUSIONS There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected. PROSPERO REGISTRATION NUMBER CRD42019125570.
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Affiliation(s)
- Nataliya Brima
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine/University College Hospital, University of Ibadan, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | | | - Justine Davies
- University of Birmingham Institute of Applied Health Research, Birmingham, UK
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Kivlehan SM, Hexom BJ, Bonney J, Collier A, Nicholson BD, Quao NSA, Rybarczyk MM, Selvam A, Rees CA, Roy CM, Bhaskar N, Becker TK. Global emergency medicine: A scoping review of the literature from 2021. Acad Emerg Med 2022; 29:1264-1274. [PMID: 35913419 DOI: 10.1111/acem.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/17/2022] [Accepted: 07/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers. METHODS A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary. RESULTS The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%). CONCLUSIONS The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.
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Affiliation(s)
- Sean M Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Humanitarian Initiative, Cambridge, Massachusetts, USA
| | - Braden J Hexom
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph Bonney
- Department of Emergency Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Global Health and Infectious Disease Research Group, Kumasi Center for Collaborative Research in Tropical Medicine, Kumasi, Ghana
| | - Amanda Collier
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Benjamin D Nicholson
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Nana Serwaa A Quao
- Department of Emergency Medicine, Accident and Emergency Centre, Korle Bu Teaching Hospital, Accra, Ghana
| | - Megan M Rybarczyk
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anand Selvam
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charlotte M Roy
- Department of Emergency Medicine, Loma Linda University, Loma Linda, California, USA
| | | | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
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Keating EM, Sakita F, Mmbaga BT, Amiri I, Nkini G, Rent S, Fino N, Young B, Staton CA, Watt MH. Three delays model applied to pediatric injury care seeking in Northern Tanzania: A mixed methods study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000657. [PMID: 36962759 PMCID: PMC10021368 DOI: 10.1371/journal.pgph.0000657] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/21/2022] [Indexed: 06/18/2023]
Abstract
Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting.
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Affiliation(s)
- Elizabeth M. Keating
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Francis Sakita
- Emergency Medical Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke-KCMC Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Ismail Amiri
- Duke-KCMC Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Getrude Nkini
- Duke-KCMC Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Sharla Rent
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Nora Fino
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Bryan Young
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Catherine A. Staton
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Melissa H. Watt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
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29
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Armstrong E, Yin X, Razee H, Pham CV, Sa-Ngasoongsong P, Tabu I, Jagnoor J, Cameron ID, Yang M, Sharma V, Zhang J, Close JCT, Harris IA, Tian M, Ivers R. Exploring Barriers to, and Enablers of, Evidence-Informed Hip Fracture Care in Five Low- Middle-Income Countries: China, India, Thailand, the Philippines and Vietnam. Health Policy Plan 2022; 37:1000-1011. [PMID: 35678318 DOI: 10.1093/heapol/czac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 05/02/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Globally, populations are ageing and the estimated number of hip fractures will increase from 1.7 million in 1990 to more than 6 million in 2050. The greatest increase in hip fractures is predicted in Low- and Middle‑Income Countries (LMICs), largely in the Asia-Pacific region where direct costs are expected to exceed $US15 billion by 2050. The aims of this qualitative study are to identify barriers to, and enablers of, evidence informed hip fracture care in LMICs, and to determine if the Blue Book standards, developed by the British Orthopaedic Association and British Geriatrics Society to facilitate evidence informed care of patients with fragility fractures, are applicable to these settings. This study utilised semi-structured interviews with clinical and administrative hospital staff to explore current hip fracture care in LMICs. Transcribed interviews were imported into NVivo 12 and analysed thematically. Interviews were conducted with 35 participants from eleven hospitals in five countries. We identified five themes-costs of care and the capacity of patients to pay, timely hospital presentation, competing demands on limited resources, delegation and defined responsibility, and utilisation of available data-and within each theme, barriers and enablers were distinguished. We found a mismatch between patient needs and provision of recommended hip fracture care, which in LMICs must commence at the time of injury. This study describes clinician and administrator perspectives of the barriers to, and enablers of, high quality hip fracture care in LMICs; results indicate that initiatives to overcome barriers (in particular, delays to definitive treatment) are required. While the Blue Book offers a starting point for clinicians and administrators looking to provide high quality hip fracture care to older people in LMICs, locally developed interventions are likely to provide the most successful solutions to improving hip fracture care.
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Affiliation(s)
| | - Xuejun Yin
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Husna Razee
- School of Population Health, UNSW Sydney, Australia
| | - Cuong Viet Pham
- Centre for Injury Policy and Prevention Research, Hanoi University of Public Health, Hanoi, Vietnam
| | - Paphon Sa-Ngasoongsong
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Irewin Tabu
- Orthopedic Trauma Division and Arthroplasty Service, University of the Philippines Manila -Philippine General Hospital, The Philippines
| | - Jagnoor Jagnoor
- Injury Division, The George Institute for Global Health, New Delhi, India.,UNSW Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney, St Leonards, Australia
| | - Minghui Yang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Vijay Sharma
- Department of Orthopaedics, JPN Apex Trauma Centre, AIIMS, New Delhi, India
| | - Jing Zhang
- School of Population Health, UNSW Sydney, Australia
| | - Jacqueline C T Close
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Sydney, Australia; Prince of Wales Clinical School, UNSW Sydney, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, Australia; Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Healt, UNSW Sydneyh, Australia.,School of Public Health, Harbin Medical University, Harbin, China
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Prolonged Casualty Care: Extrapolating Civilian Data to the Military Context. J Trauma Acute Care Surg 2022; 93:S78-S85. [PMID: 35546736 DOI: 10.1097/ta.0000000000003675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource-limitations, and system configuration to U.S. military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations. METHODS We conducted a 6 month analysis of an on-going, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape ('EpiC'). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using chi-squared and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models. RESULTS 146 of 995 patients experienced PCC. The PCC group, compared to non-PCC, were more critically injured (66% vs 51%), received more critical interventions (36% vs 29%), had a greater proportionate mortality (5% vs 3%), longer hospital stays (3 vs 1 day), and higher SOFA scores (5 vs 3). The odds of 7-day mortality and a SOFA score ≥ 5 were 1.6 (OR: 1.59; 0.68, 3.74) and 3.6 (OR: 3.69; 2.11, 6.42) times higher, respectively, in PCC versus non-PCC patients. CONCLUSIONS EpiC enrolled critically injured patients with PCC who received resuscitative interventions. PCC patients had worse outcomes than non-PCC. EpiC will be a useful platform to provide on-going data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care. LEVEL OF EVIDENCE III; prospective comparative study.
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31
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Odland ML, Abdul-Latif AM, Ignatowicz A, Alayande B, Appia Ofori B, Balanikas E, Bekele A, Belli A, Chu K, Ferreira K, Howard A, Nzasabimana P, Owolabi EO, Nyamathe S, Pognaa Kunfah SM, Tabiri S, Yakubu M, Whitaker J, Byiringiro JC, Davies JI. Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa. BMJ Glob Health 2022; 7:bmjgh-2021-008256. [PMID: 35410954 PMCID: PMC9003614 DOI: 10.1136/bmjgh-2021-008256] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 02/18/2022] [Indexed: 11/23/2022] Open
Abstract
Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.
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Affiliation(s)
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK .,Department of Obstetrics and Gynecology, St. Olavs University Hospital, Trondheim, Norway.,Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
| | - Abdul-Malik Abdul-Latif
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Volta Regional Health Directorate, Ghana Health Service, Accra, Greater Accra, Ghana
| | | | - Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda.,Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Antonio Belli
- University of Birmingham, Birmingham, UK.,National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.,Department of Surgery, University of Botswana, Gaborone, Botswana
| | - Karen Ferreira
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Anthony Howard
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Centre, University of Oxford, Headington, Oxford, UK
| | | | - Eyitayo O Owolabi
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Samukelisiwe Nyamathe
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | | | - Stephen Tabiri
- Ghana HUB of NIHR Global Surgery, Tamale, Ghana.,Department of Public Health, Tamale Teaching Hospital, Tamale, Ghana.,Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Mustapha Yakubu
- Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana.,School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Jean Claude Byiringiro
- University of Rwanda, Kigali, Rwanda.,Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.,Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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32
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Sawe HR, Milusheva S, Croke K, Karpe S, Mohammed M, Mfinanga JA. Burden of Road Traffic Injuries in Tanzania: One-Year Prospective Study of Consecutive Patients in 13 Multilevel Health Facilities. Emerg Med Int 2021; 2021:4272781. [PMID: 34804611 PMCID: PMC8598361 DOI: 10.1155/2021/4272781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/14/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Road traffic injuries (RTIs) pose a severe public health crisis in Sub-Saharan Africa (SSA) and specifically in Tanzania, where the mortality due to RTIs is nearly double the global rate. There is a paucity of RTI data in Tanzania to inform evidence-based interventions to reduce the incidence and improve care outcomes. A trauma registry was implemented at 13 health facilities of diverse administrative levels in Tanzania. In this study, we characterize the burden of RTIs seen at these health facilities. METHODS This was a one-year prospective descriptive study utilizing trauma registry data from 13 multilevel health facilities in Tanzania from 1 October 2019 to 30 September 2020. We provide descriptive statistics on patient demographics; location; share of injury; nature, type, and circumstances of RTI; injury severity; disposition; and outcomes. RESULTS Among 18,553 trauma patients seen in 13 health facilities, 7,416 (40%) had RTIs. The overall median age was 28 years (IQR 22-38 years), and 79.3% were male. Most road traffic crashes (RTC) occurred in urban settings (68.7%), involving motorcycles (68.3%). Motorcyclists (32.9%) were the most affected road users; only 37% of motorcyclists wore helmets at the time of the crash. The majority (88.2%) of patients arrived directly from the site, and 49.0% used motorized (two- or three-) wheelers to travel to the health facility. Patients were more likely to be admitted to the ward, taken to operating theatre, died at emergency unit (EU), or referred versus being discharged if they had intracranial injuries (27.8% vs. 3.7%; p < 0.0001), fracture of the lower leg (18.9% vs. 6.4%; p < 0.0001), or femur fracture (12.9% vs. 0.4%; p < 0.0001). Overall, 36.1% of patients were admitted, 10.6% transferred to other facilities, and mortality was 2%. CONCLUSIONS RTCs are the main cause of trauma in this setting, affecting mostly working-age males. These RTCs result in severe injuries requiring hospital admission or referral for almost half of the victims. Motorcyclists are the most affected group, in alignment with prior studies. These findings demonstrate the burden of RTCs as a public health concern in Tanzania and the need for targeted interventions with a focus on motorcyclists.
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Affiliation(s)
- Hendry R. Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Emergency Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Sveta Milusheva
- Development Impact Evaluation Group, World Bank, Washington, DC, USA
| | - Kevin Croke
- Development Impact Evaluation Group, World Bank, Washington, DC, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | - Meyhar Mohammed
- Development Impact Evaluation Group, World Bank, Washington, DC, USA
| | - Juma A. Mfinanga
- Department of Emergency Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
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33
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Budema PM, Murhega RB, Tshimbombu TN, Toha GK, Cikomola FG, Mudekereza PS, Mubenga LE, Maheshe-Balemba G, Badesire DC, Kanmounye US. Fatal and nonfatal firearm injuries in the eastern Democratic Republic of Congo: a hospital-based retrospective descriptive cohort study assessing correlates of adult mortality. BMC Emerg Med 2021; 21:116. [PMID: 34641813 PMCID: PMC8506075 DOI: 10.1186/s12873-021-00506-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The Eastern Democratic Republic of Congo (DRC) has been the battleground for multiple armed conflicts, resulting in many fatal and nonfatal firearm injuries (F&NFFIs). Chronic insecurity has stressed the health system’s resources and created barriers to seeking, reaching, and receiving timely care further increasing the F&NFFI burden. Our institution is the largest trauma center in the region and receives the bulk of F&NFFI cases. We aimed to identify correlates of mortality in Congolese F&NFFI patients. Methods We included all F&NFFI patients admitted to our institution between 2017 and 2020. We extracted data from patient charts and admission logs. We identified mortality correlates using the two-sample t-test, Chi-square test, and multivariable regression analysis. A P-value of less than 0.05 was considered statistically significant. Results This study included 814 adult patients, mostly male (86%) with an average age of 34.5 years and living 154.4 km away from the hospital on average. The most affected anatomical sites were the lower limbs (48.2%) and upper limbs (23.2%). The median length of stay was 34.0 days, and the in-hospital mortality rate was 3.6%. In addition, mortality was negatively correlated with diastolic blood pressure (P = 0.01), SaO2 (P < 0.001), and hemoglobin concentration (P = 0.002). Conclusion F&NFFIs cause an enormous burden in the region, and mortality is correlated with some clinical and biological variables. Thus, the study findings will inform F&NFFI referral, triage, and management in low-resource and mass casualty settings.
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Affiliation(s)
- Paul Munguakonkwa Budema
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Roméo Bujiriri Murhega
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo.,Research Department, Association of Future African Neurosurgeons, 37B Avenue des Marais, Forgeron, Funa, Kinshasa, Democratic Republic of Congo
| | - Tshibambe Nathanael Tshimbombu
- Research Department, Association of Future African Neurosurgeons, 37B Avenue des Marais, Forgeron, Funa, Kinshasa, Democratic Republic of Congo.,Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH, 03755, USA
| | - Georges Kuyigwa Toha
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Fabrice Gulimwentuga Cikomola
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Paterne Safari Mudekereza
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Léon-Emmanuel Mubenga
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ghislain Maheshe-Balemba
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo.,Department of Radiology, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo
| | - Darck Cubaka Badesire
- Department of Surgery, Provincial General Reference Hospital of Bukavu, Bukavu, Democratic Republic of Congo.,Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ulrick Sidney Kanmounye
- Research Department, Association of Future African Neurosurgeons, 37B Avenue des Marais, Forgeron, Funa, Kinshasa, Democratic Republic of Congo.
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Are Trauma Surgery Simulation Courses Beneficial in Low- and Middle-Income Countries—A Systematic Review and Meta-Analysis. TRAUMA CARE 2021. [DOI: 10.3390/traumacare1030012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite trauma-related injuries being a leading cause of death worldwide, low- and middle-income countries (LMICs) lack the infrastructure and resources required to offer immediate surgical care, further perpetuating the risk of morbidity and mortality. In high-income countries, trauma surgery simulation courses are routinely delivered to surgeons, teaching the fundamental skills of operative trauma. This study aimed to assess whether similar courses are beneficial in LMICs and how they can be improved. We performed a systematic review and meta-analysis using MEDLINE, Embase and Google Scholar, analysing studies evaluating trauma surgery simulation in LMICs. The outcomes measured included clinical knowledge improvement, participant confidence and general course-feedback. The review was carried out in-line with PRISMA guidelines. Five studies were included, summating a population of 172 participants. In three studies, meta-analysis showed an overall significant weighted mean improvement of knowledge post-course by 22.91% (95%CI 19.53, 26.29; p < 0.00001; I2 = 0%). One study reported a significant increase in participant confidence for 20/22 of operative skills taught (p < 0.04). We conclude that these courses are beneficial in LMICs; however, further research is necessary to establish the optimum course design, and whether patient outcomes are improved following their implementation. Collaboration between international trauma institutions is essential for closing the educational resource inequality gap between higher- and lower-income countries.
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