Low utilization of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma

Community perspectives on barriers to injury care in Northern Malawi: a three delays framed assessment using focus groups and photovoice

INTRODUCTION

The global burden of injury is huge, falling disproportionately on poorer populations. The benefits of qualitative research in injury care are recognised and its application is growing. We used a novel application of focus group discussions with photovoice to rapidly assess barriers at each of three delay stages; seeking (delay-1), reaching (delay-2) or receiving (delay-3) injury care in Northern Malawi.

METHODS

Three community Focus Group Discussions (FGDs) of individuals with (FGD1) and without (FGD2) recent injury experience and community leaders (FGD3) discussed barriers to seeking, reaching or receiving care following injury. Participants from FGD1 subsequently used a digital camera and, following training in photovoice, took photographs illustrating barriers to injury care. Participants reconvened to discuss images which they believed illustrated important barriers. A framework method analysis compared barriers generated to those identified by an earlier Delphi study.

RESULTS

Seven of eight invited adult community members attended each discussion group. Within the FGDs, all prior Delphi derived delay 1 barriers were described. Within delay 2, all but three were discussed by community participants. Those not covered were: 1) "communication" ;2) "prehospital care"; 3) "coordination". Within Delay 3, only "capacity"was not highlighted by participants during the study. Additional health system barriers not identified in the Delphi were inductively derived. Within Delay 1, these were labelled; "religious or other beliefs"; "indecision"; "fear or lacking courage"; and "community/bystander engagement". Within Delay 2, "lack of assistance" was derived. Within Delay 3; "alleged corruption"; "interfacility transfer"; and "police processes" were all identified during analysis. The photovoice group provided 21 photographs evidencing 15 barriers. Delay 1 was the most frequently captured by images (12/21).The individual barriers most frequently described were "transport" and "roads" (6/21 and 5/21, respectively). The photovoice group did not describe any additional barriers not covered in the prior FGDs.

CONCLUSION

We identified several barriers within this health system. Participants illustrated how some barriers impact on multiple phases of delay. The method was quick, low cost and participants grasped the technique and research question effectively. We recommend this approach for future health system assessments.

Access to quality care after injury in Northern Malawi: results of a household survey

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.

Limb Injuries and Disability in the Southwest Region of Cameroon

INTRODUCTION

Extremity injuries are a leading cause of morbidity in low- and middle-income countries (LMICs), often resulting in marked short-term and long-term disabilities. Most of the existing knowledge on these injuries originates from hospital-based studies; however, poor access to health care in LMICs limits these data because of inherent selection bias. This subanalysis of a larger population-level cross-sectional study in the Southwest Region of Cameroon aims to determine patterns of limb injury, treatment-seeking behaviors, and predictors of disability.

METHODS

Households were surveyed in 2017 on injuries and subsequent disability sustained over the previous 12 months using a three-stage cluster sampling framework. Subgroups were compared using the chi square, Fisher exact, analysis of variance, Wald, and Wilcoxon rank-sum tests. Logarithmic models were used to identify predictors of disability.

RESULTS

Of 8,065 subjects, 335 persons (4.2%) sustained 363 isolated limb injuries. Over half of the isolated limb injuries (55.7%) were open wounds while 9.6% were fractures. Isolated limb injuries most commonly occurred in younger men and resulted from falls (24.3%) and road traffic injuries (23.5%). High rates of disability were reported, with 39% reporting difficulty with activities of daily living. Compared with individuals with other types of limb injuries, those with fractures were six times more likely to seek a traditional healer first for care (40% versus 6.7%), 5.3 times (95% CI, 1.21 to 23.42) more likely to have any level of disability after adjustment for injury mechanism, and 2.3 times more likely to have difficulty paying for food or rent (54.8% versus 23.7%).

DISCUSSION

Most traumatic injuries sustained in LMICs involve limb injuries and often result in high levels of disability that affect individuals during their most productive years. Improved access to care and injury control measures, such as road safety training and improvements to transportation and trauma response infrastructure, are needed to reduce these injuries.

Too serious to ignore: The epidemiologic and economic burden of home injuries in the Southwest Region of Cameroon-A community-based study

BACKGROUND

Home injuries are an important cause of morbidity and mortality in high-income countries. In Sub-Saharan Africa, including Cameroon, many people live in unplanned settlements with poorly constructed houses, predisposing them to home injuries. However, little is known about the epidemiology and care-seeking behaviors of the domestically injured. In this study, our objective was to determine the epidemiology and care-seeking behaviors of home injuries in the Southwest Region of Cameroon.

METHODS

A sub-analyses of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months was conducted. Sampling was done using three-stage cluster sampling technique. Differences between groups were evaluated using Chi-squared and Adjusted Wald tests.

RESULTS

Of 8065 participants, 157 suffered home injuries giving an incidence of 19.6 (16.8-23.0 95% CI) cases per 1000-person years. Home injuries comprised 31.2% of all 503 injuries and affected more females (60.8%) and younger individuals (mean age (SE) 25.1 years (2.0)) than non-home injuries. The most common activity and mechanism of home injury was leisure/play (51%) and falls (37.9%) respectively. Amongst those with home injuries, 37.6% did not seek care from any care provider (versus 25.0% of non-home injuries, p = 0.004) and were more likely to seek treatment within the family or at home (p = 0.008) or at church (p = 0.010). Those with home injuries experienced a median of 14 disability days and 22.9% of families faced difficulties affording basic expenses (p = 0.001).

CONCLUSION

Home injuries comprise about a third of the Southwest Region of Cameroon's burden of injury and likely have a profound socioeconomic impact. Though these injuries cause severe disabilities, a large proportion of victims do not seek care from providers. Prevention efforts should address the design of homes and victims of home injury should be encouraged to utilize formal care services.

Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study

OBJECTIVES

In Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death and disability in Cameroonian trauma patients over a 6-month period after hospital discharge.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the Littoral and Southwest regions of Cameroon.

PARTICIPANTS

A total of 1914 patients entered the study, 1304 were successfully contacted. Inclusion criteria were patients discharged after being treated for traumatic injury at each of four participating hospitals during a 20-month period. Those who did not possess a cellular phone or were unable to provide a phone number were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Glasgow Outcome Scale-Extended (GOSE) was administered to trauma patients at 2 weeks, 1 month, 3 months and 6 months post discharge. Median GOSE scores for each timepoint were compared and regression analyses were performed to determine associations with death and disability.

RESULTS

Of 71 deaths recorded, 90% occurred by 2 weeks post discharge. At 6 months, 22% of patients still experienced severe disability. Median (IQR) GOSE scores at the four timepoints were 4 (3-7), 5 (4-8), 7 (4-8) and 7 (5-8), respectively, (p<0.01). Older age was associated with greater odds of postdischarge disability (OR: 1.23, 95% CI: 1.07 to 1.41) and mortality (OR: 2.15, 95% CI: 1.52 to 3.04), while higher education was associated with decreased odds of disability (OR: 0.65, 95% CI: 0.58 to 0.73) and mortality (OR: 0.38, 95% CI: 0.31 to 0.47). Open fractures (OR: 1.73, 95% CI: 1.38 to 2.18) and closed fractures (OR: 1.83, 95% CI: 1.42 to 2.36) were associated with greater postdischarge disability, while higher Injury Severity Score (OR: 2.44, 95% CI: 2.13 to 2.79) and neurological injuries (OR: 4.40, 95% CI: 3.25 to 5.96) were associated with greater odds of postdischarge mortality.

CONCLUSION

Mobile follow-up data show significant morbidity and mortality, particularly for orthopaedic and neurologic injuries, up to 6 months following trauma discharge. These results highlight the need for reliable follow-up systems in Cameroon.

Epidemiology of Patients with Head Injury at a Tertiary Hospital in Rwanda

Introduction

Traumatic injuries disproportionately affect populations in low and middle-income countries (LMIC) where head injuries predominate. The Rwandan Ministry of Health (MOH) has dramatically improved access to emergency services by rebuilding its health infrastructure. The MOH has strengthened the nation’s acute emergency response by renovating emergency departments (ED), developing the field of emergency medicine as a specialty, and establishing a prehospital care service: Service d’Aide Medicale Urgente (SAMU). Despite the prevalence of traumatic injury in LMIC and the evolving emergency service in Rwanda, data regarding head trauma epidemiology is lacking.

Methods

We conducted this retrospective cohort study at the University Teaching Hospital of Kigali (UTH-K) and used a linked prehospital database to investigate the demographics, mechanism, and degree of acute medical interventions amongst prehospital patients with head injury.

Results

Of the 2,426 patients transported by SAMU during the study period, 1,669 were found to have traumatic injuries. Data from 945 prehospital patients were accrued, with 534 (56.5%) of these patients diagnosed with a head injury. The median age was 30 years, with most patients being male (80.3%). Motor vehicle collisions accounted for almost 78% of all head injuries. One in six head injuries were due to a pedestrian struck by a vehicle. Emergency department interventions included intubations (6.7%), intravenous fluids (2.4%), and oxygen administration (4.9%). Alcohol use was not evaluated or could not be confirmed in 81.3% of head injury cases. The median length of stay (LOS) in the ED was two days (interquartile range: 1,3). A total of 184 patients were admitted, with 13% requiring craniotomies; their median in-hospital care duration was 13 days.

Conclusion

In this cohort of Rwandan trauma patients, head injury was most prevalent amongst males and pedestrians. Alcohol use was not evaluated in the majority of patients. These traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of head injury, may be beneficial in the Rwandan setting.

Trauma Care in Low- and Middle-Income Countries

Background  Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.

Methods  A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.

Results  Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.

Conclusion  Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.

Incidence, causes and factors associated with torso injury in Cameroon: A community-based study

BACKGROUND

Morbidity and mortality linked to injury has become an increasingly important public health concern worldwide, especially in developing countries. Despite the potentially severe nature of torso injury, little is known about the population-based epidemiology of torso injury in sub-Saharan Africa.

OBJECTIVES

To determine the incidence, identify common mechanisms, and assess the socioeconomic consequences of torso injury in Cameroon.

METHODS

We performed a torso injury sub-analysis of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months in the Southwest region of Cameroon. Sampling was done using the three-stage cluster sampling technique. The differences between groups were evaluated using χ² and adjusted Wald tests.

RESULTS

We identified 39 cases of torso injuries out of 8 065 participants, providing a yearly incidence estimate of 488 (95% confidence interval (CI) 356 - 668) per 100 000 person-years. Road traffic injury was the most common mechanism of torso injury. The median (interquartile range (IQR)) cost of treatment for torso injury was USD58 (10 - 137), over four times the median (IQR) cost for non-torso injury at USD12 (3 - 43) (p=0.0004). About half of affected households (51%) reported being unable to afford necessities such as rent and food after injury v. 33% of households with members with non-torso injuries (p=0.018).

CONCLUSION

Torso injuries have an incidence of 488/100 000 person-years, and road traffic injuries account for the majority of the injuries. Road traffic control measures and trauma care strengthening may reduce the impact of torso injuries and injuries in Cameroon.

Epidemiology of traumatic brain injury based on clinical symptoms amongst inhabitants of the Southwest Region of Cameroon: a community-based study

BACKGROUND

The majority of studies investigating the epidemiology of traumatic brain injury (TBI) in sub-Saharan Africa are primarily hospital-based, missing fatal, mild, and other cases of TBI that do not present to formal care settings. This study aims to bridge this gap in data by describing the epidemiology of TBI in the Southwest Region of Cameroon.

METHODS

This was a cross-sectional community-based study. Using a three-stage cluster sampling, local research assistants surveyed households with a pre-tested questionnaire to identify individuals with symptoms of TBI in nine health districts in the Southwest Region of Cameroon from 2016 to 2017.

RESULTS

Data gathered on 8,065 individuals revealed 78 cases of suspected TBI. Road traffic injury (RTI) comprised 55% of subjects' mechanism of injury. Formal medical care was sought by 82.1% of subjects; three subjects died at the time of injury. Following injury, 59% of subjects reported difficulty affording basic necessities and 87.2% of subjects were unable to perform activities of their primary occupation.

CONCLUSIONS

This study postulates an incidence of TBI in Southwest Cameroon of 975.57 per 100,000 individuals, significantly greater than prior findings. A large proportion of TBI is secondary to RTI.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Evaluating a Novel Prehospital Emergency Trauma Care Assessment Tool (PETCAT) for Low- and Middle-Income Countries in Sierra Leone

BACKGROUND

WHO recommends training lay first responders (LFRs) as the first step toward formal emergency medical services development, yet no tool exists to evaluate LFR programs.

METHODS

We developed Prehospital Emergency Trauma Care Assessment Tool (PETCAT), a seven-question survey administered to first-line hospital-based healthcare providers, to independently assess LFR prehospital intervention frequency and quality. PETCAT surveys were administered one month pre-LFR program launch (June 2019) in Makeni, Sierra Leone and again 14 months post-launch (August 2020). Using a difference-in-differences approach, PETCAT was also administered in a control city (Kenema) with no LFR training intervention during the study period at the same intervals to control for secular trends. PETCAT measured change in both the experimental and control locations. Cronbach's alpha, point bi-serial correlation, and inter-rater reliability using Cohen's Kappa assessed PETCAT reliability.

RESULTS

PETCAT administration to 90 first-line, hospital-based healthcare providers found baseline prehospital intervention were rare in Makeni and Kenema prior to LFR program launch (1.2/10 vs. 1.8/10). Fourteen months post-LFR program implementation, PETCAT demonstrated prehospital interventions increased in Makeni with LFRs (5.2/10, p < 0.0001) and not in Kenema (1.2/10) by an adjusted difference of + 4.6 points/10 (p < 0.0001) ("never/rarely" to "half the time"), indicating negligible change due to secular trends. PETCAT demonstrated high reliability (Cronbach's α = 0.93, Cohen's K = 0.62).

CONCLUSIONS

PETCAT measures changes in rates of prehospital care delivery by LFRs in a resource-limited African setting and may serve as a robust tool for independent EMS quality assessment.

Feasibility of a Cellular Telephone Follow-Up Program After Injury in Sub-Saharan Africa

BACKGROUND

Injury disproportionately affects persons in low- and middle-income countries (LMIC). Most LMIC lack capacity for routine follow-up care, likely resulting in complications and disability. Cellular telephones may provide a new tool to improve health outcomes. The objective of this study was to establish the feasibility of a mobile health follow-up program after injury in Cameroon.

METHODS

Between February and October 2017, all injured patients admitted to a regional hospital in Cameroon were asked for mobile phone numbers as part of an existing trauma registry. Patients were contacted 2 weeks after leaving the hospital discharge to participate in a short triage survey. Data on program feasibility and patient condition were collected.

RESULTS

Of 1180 injured patients who presented for emergency care, 83% provided telephone numbers, 62% were reached, and 48% (565) of all injured patients ultimately participated in telephone follow-up. Successfully contacted patients were reached after an average of 1.76 call attempts (SD 1.91) and median call time was 4.43 min (IQR 3.67-5.36). Five patients (1%) had died from their injuries at the time of follow-up. Among surveyed patients, 27% required ongoing assistance to complete activities of daily living. Nearly, half (47%) of patients reported inability to take medicines or care for their injury as instructed at discharge. Adequate pain control was achieved in only 38% of discharged patients.

CONCLUSION

Pilot data suggest considerable under treatment of injury in Cameroon. Mobile telephone follow-up demonstrates potential as a feasible tool for screening discharged patients who could benefit from further care.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Background

About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods

This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results

Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions

The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.

PROSPERO registration number

CRD42017064600.

Association of Health Care Use and Economic Outcomes After Injury in Cameroon

IMPORTANCE

Despite the highest injury rates worldwide, formal medical care is not often sought after injuries in Sub-Saharan Africa. Unaffordable costs associated with trauma care might inhibit injured patients from seeking care.

OBJECTIVES

To (1) determine the injury epidemiology in Cameroon using population-representative data, (2) identify the barriers to use of formal health care after injury, and (3) determine the association between use of care and economic outcomes after injury.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-methods, cross-sectional study included a population-representative, community-based survey and nested qualitative semistructured interviews in the urban-rural Southwest Region of Cameroon. Three-stage cluster sampling was used to select target households. Data were collected from January 3 to March 14, 2017, and analyzed from March 3, 2017, to March 3, 2019.

EXPOSURES

Injuries occurring in the preceding 12 months.

MAIN OUTCOMES AND MEASURES

Postinjury use of health care services, disability, and economic outcomes. All survey data were adjusted for cluster sampling.

RESULTS

Of 1551 total households approached, 1287 (83.0%) were surveyed for a total sample size of 8065 participants. The 8065 individuals surveyed included 4181 women (52.0%), with a mean age of 23.9 (standard error [SE], 0.2) years. A total of 503 injuries were identified among 471 unique participants, including 494 nonfatal injuries. Among these, 165 (34.6%) did not seek formal medical services. Disability occurred after 345 injuries (68.6%) and resulted in 11 941 lost days of work in the sample. Family economic hardship after injury was substantially increased among the injured cohort who used formal medical care. Injuries brought to formal medical care, compared with those that were note, incurred higher mean treatment costs ($101.08 [SE, $236.23] vs $12.13 [SE, $36.78]; P < .001), resulted in higher rates of lost employment (19.9% [SE, 3.6%] vs 5.6% [SE, 1.6%]; P = .004), and more frequently led affected families to use economic coping strategies, such as borrowing money (26.2% [SE, 2.7%] vs 7.1% [SE, 1.2%]; P < .001). After adjusting for age and severity, use of formal medical care in Cameroon was independently associated with severe economic hardship after injury, defined as a new inability to afford food or rent (adjusted odds ratio, 1.67; 95% CI, 1.05-2.65).

CONCLUSIONS AND RELEVANCE

In this study, injury in Southwestern Cameroon was associated with significant disability and lost productivity. Formal medical treatment of injury was associated with significant financial consequences for households of injured patients. Primary prevention of road traffic injuries and financial restructuring of emergency care could improve trauma care access in Cameroon and reduce the societal effects of injury.

A Qualitative Study of Transitions Between Health Care Settings After Injury in Cameroon

BACKGROUND

Populations in Cameroon, a lower middle-income country in Central Africa, have a higher than average burden of traumatic injury, suffer from more severe injuries, and face substantial barriers to accessing formal health care services after injury. The aim of this study was to identify and describe how recently injured Cameroonians use and adapt the formal and informal medical systems and what motivates these transitions.

MATERIALS AND METHODS

Recently injured people or their surrogates residing in Southwest Region, Cameroon, were recruited from a larger community-based survey on injury. Semistructured interviews were conducted with 39 recently injured persons or their adult family members. Interviews were recorded, transcribed, and iteratively coded to identify major themes.

RESULTS

Most injured persons had complex therapeutic itineraries involving one or more transitions, and nine of 35 injured persons used formal care exclusively. Transitions away from formal care were driven by (1) anticipated costs beyond means, (2) unacceptable length of proposed treatment, (3) poorly supported referrals, (4) dissatisfaction with treatment progress or outcome, and (5) belief that traditional methods work additively with formal care. Factors motivating people to engage with formal care included (1) perceived high value of care for cost, (2) desire for reliable diagnostic tests, (3) social support during hospitalization, and (4) financial support from family or a stranger responsible for the injury.

CONCLUSIONS

These results highlight specific opportunities to improve engagement in formal care after injury and better support injured Cameroonians through the strengthening of the formal care referral process and health financing organization.

Road traffic injuries: Cross-sectional cluster randomized countrywide population data from 4 low-income countries

INTRODUCTION

Road traffic injuries (RTI) are a leading cause of morbidity and mortality around the world. The burden is highest in low and middle-income countries (LMICs) and is increasing. We aimed to describe the epidemiology of RTIs in 4 low-income countries using nationally representative survey data.

METHODS

The Surgeons Overseas Assessment of Surgical Needs (SOSAS) survey tool was administered in four countries: Sierra Leone, Rwanda, Nepal and Uganda. We performed nationally representative cross-sectional, cluster randomized surveys in each country. Information regarding demographics, injury characteristics, anatomic location of injury, healthcare seeking behavior, and disability from injury was collected. Data were reported with descriptive statistics and evaluated for differences between the four countries using statistical tests where appropriate.

RESULTS

A total of 13,765 respondents from 7115 households in the four countries were surveyed. RTIs occurred in 2.2% (2.0-2.5%) of the population and accounted for 12.9% (11.5-14.2%) of all injuries incurred. The mean age was 34 years (standard deviation ±1years); 74% were male. Motorcycle crashes accounted for 44.7% of all RTIs. The body regions most affected included head/face/neck (36.5%) followed by extremity fractures (32.2%). Healthcare was sought by 78% road injured; 14.8% underwent a major procedure (requiring anesthesia). Major disability resulting in limitations of work or daily activity occurred in 38.5% (33.0-43.9%).

CONCLUSION

RTIs account for a significant proportion of disability from injury. Younger men are most affected, raising concerns for potential detrimental consequences to local economies. Prevention initiatives are urgently needed to stem this growing burden of disease; additionally, improved access to timely emergency, trauma and surgical care may help alleviate the burden due to RTI in LMICs.

Variations in injury characteristics among paediatric patients following trauma: A retrospective descriptive analysis comparing pre-hospital and in-hospital deaths at Kamuzu Central Hospital, Lilongwe, Malawi

Background

Trauma is a major cause of paediatric mortality in sub-Saharan Africa. In absence of pre-hospital care, the injury mechanism and cause of death is difficult to characterise. Injury characteristics of pre-hospital deaths (PHD) versus in-hospital deaths (IHD) were compared.

Methods

Using our trauma surveillance database, a retrospective, descriptive analysis of children (<18 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi from 2008 to 2013 was performed. Patient and injury characteristics of pre-hospital and in-hospital deaths were compared with univariate and bivariate analysis.

Results

Of 30,462 paediatric trauma patients presenting between 2008 and 2013, 170 and 173 were PHD and IHD, respectively. In PHD and IHD patients mean age was 7.3±4.9 v 5.2±4.3 (p<0.001), respectively. IHD patients were more likely transported via ambulance than those PHD, 51.2% v 8.3% (p<0.001). The primary mechanisms of injury for PHD were road traffic injuries (RTI) (45.8%) and drowning (22.0%), with head injury (46.7%) being the predominant cause of death. Burns were the leading mechanism of injury (61.8%) and cause of death (61.9%) in IHD, with a mean total body surface area involvement of 24.7±16.0%.

Conclusions

RTI remains Malawi's major driver of paediatric mortality. A majority of these deaths attributed to head injury occur prior to hospitalisation; therefore the mortality burden is underestimated if accounting for IHD alone. Death in burn patients is likely due to under-resuscitation or sepsis. Improving pre-hospital care and head injury and burn management can improve injury related paediatric mortality.

Musculoskeletal disease in Nepal: A countrywide cross-sectional survey on burden and surgical access

INTRODUCTION

Musculoskeletal disease (MSD) is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in low and middle-income countries (LMICs) are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure incidence and prevalence of surgically treatable conditions, including MSD, in patients in LMICs.

METHODS

A countrywide survey was done in Nepal using SOSAS in May-June 2014. Clusters were chosen based on population weighted random sampling. Chi squared tests and multivariate logistic regression assessed associations between demographic variables and MSD.

RESULTS

Self-reported MSDs were seen in 14.8% of survey respondents with an unmet need of 60%. The majority of MSDs (73.9%) occurred between 1 and 12 months prior to the survey. Female sex (OR = 0.6; p < 0.000), access to motorized transport (for secondary facility, OR = 0.714; p < 0.012), and access to a tertiary health facility (OR = 0.512; p < 0.008) were associated with lower odds of MSD.

DISCUSSION

Based on this study, there are approximately 2.35 million people living with MSDs in Nepal. As the study identified non-availability, lack of money, and fear and/or lack of trust as the major barriers to orthopedic care in Nepal, future work should consider interventions to address these barriers.

CONCLUSION

There is a need to increase surgical capacity in LMICs; in particular, there is a need to bolster trauma and orthopedic care. Previous studies have suggested ways to allocate resources to build capacity. We recommend targeting the alleviation of these identified barriers in parallel with capacity building.

Effect of First Aid Education on First Aid Knowledge and Skills of Commercial Drivers in South West Nigeria

BACKGROUND

Prompt prehospital care is essential for improving outcomes of road crash victims; however, this service is sub-optimal in developing countries because Emergency Medical Services (EMS) are not readily available. Training of lay responders in first aid has been suggested as a means of filling this gap in settings with inadequate EMS. This study was conducted to determine the effect of first aid training on the first aid knowledge and skills of commercial drivers.

METHODS

A before-and-after study was conducted among 128 commercial drivers (62 intervention and 66 controls) selected by multi-stage sampling. Drivers' first aid knowledge and skills were assessed at baseline, immediate, and three months post-intervention. The intervention involved a 2-day training session in first aid. Repeated measures ANOVA was used to test for differences in respondents' pre- and post-intervention scores over the three assessment points.

RESULTS

Mean first aid knowledge scores for intervention drivers were 48.9% (SD=12.0), 57.8% (SD=11.2), and 59.2% (SD=9.0) at baseline, immediate, and three months post-intervention. Corresponding scores for the controls were 48.3% (SD=12.8), 39.2% (SD=15.3), and 46.8% (SD=15.3). Mean first aid skill scores for intervention drivers were 17.5% (SD=3.8), 80.7% (SD=8.3), and 72.3% (SD=16.8). Scores for control drivers were 16.5% (SD=4.5), 16.3% (SD=4.7), and 20.4% (SD=9.1), respectively. Repeated measures ANOVA showed significant differences in first aid knowledge and skills scores over the three phases. Independent t-test revealed significant differences in scores between the intervention and control groups post-intervention.

CONCLUSION

The training led to significant improvement in first aid knowledge and skills of intervention drivers. This confirms that lay responders can be trained in provision of first aid. The slight drop in skills scores, which occurred three months post-intervention, highlights the need for periodic refresher trainings to be conducted for the drivers in order to maintain the knowledge and skills acquired.

Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting?

BACKGROUND

Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization.

METHODS

Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test.

RESULTS

A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays.

CONCLUSIONS

The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.

Surgical need in an aging population: A cluster-based household survey in Nepal

BACKGROUND

With an aging global population comes an obligate and substantial burden of noncommunicable disease, especially in low- and middle-income countries. An unknown proportion of this burden is treatable with surgical expertise. For health system planning, this study aimed to estimate the operative needs of individuals older than 50 of age years in Nepal.

METHODS

A 2-stage, cluster randomized, community-based survey was performed in Nepal using the validated Surgeons OverSeas Surgical Assessment Survey (SOSAS). SOSAS collects household demographics and selects household members randomly for verbal, head-to-toe examinations for surgical conditions; moreover, SOSAS also completes a verbal autopsy for deaths in the preceding year. Only respondents older than 50 years were included in the analysis.

RESULTS

The survey sampled 1,350 households, totaling 2,695 individuals (97% response rate). Of these, 273 surgical conditions were reported by 507 persons ages ≥ 50 years. Extrapolating, there are potentially 2.1 million people older than 50 years of age with surgically treatable conditions who need care in Nepal (95% confidence interval 1.8-2.4 million; 46,000-62,600 per 100,000 persons). One in 5 deaths was potentially treatable or palliated by surgical care. Although growths or masses (including hernias and goiters) were the surgical condition reported most commonly (25%), injuries and fractures also were common and associated with the greatest disability. Literacy and distance to secondary and tertiary health facilities were associated with lack of care for operative conditions (P < .05).

CONCLUSION

There is a large, unmet surgical need among the elderly in Nepal. Low literacy and distance from a capable health facility are the greatest barriers to care. As the global population ages, there is an increasing need to improve surgical services and strengthen health systems to care for this group.

The burden of musculoskeletal disease in Sierra Leone

BACKGROUND

Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in developing countries are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure the incidence and prevalence of surgically treatable conditions, including musculoskeletal conditions, in patients in low- and middle-income countries, and was administered in the West African nation of Sierra Leone in 2012.

PURPOSE

We attempted to quantify the burden of potentially treatable musculoskeletal conditions in patients in Sierra Leone.

METHODS

A cross-sectional two-stage cluster-based survey was performed in Sierra Leone using the SOSAS. Two individuals from each randomly selected household underwent a verbal head to toe examination. The musculoskeletal-related questions from the SOSAS survey in Sierra Leone were analyzed to determine the prevalence of musculoskeletal problems in the study population. Prevalence is reported as the number of respondents with a musculoskeletal problem now and number of respondents with a musculoskeletal problem during the past year. Respondents had "no need" for care, they "received care", or they faced a barrier that prevented them from receiving care.

RESULTS

One thousand eight hundred seventy-five households were targeted, with 1843 undergoing the survey, which yielded 3645 individual respondents. Of the individual respondents, 462 (n=3645; 12.6% of total; 95% CI, 12%-13%) had a traumatic musculoskeletal problem during the past year, and 236 (n=3645; 6% of total; 95% CI, 5%-7%) respondents had a musculoskeletal problem of nontraumatic etiology. Of respondents with either a traumatic or nontraumatic musculoskeletal problem, 359 (n=562; 63.9% of total; 95% CI, 59.5-68.3%) needed care but were unable to receive it with the major barrier reported as financial.

CONCLUSION

Resource allocation decisions in global health are made based on burden of disease data in low- and middle-income countries. The data provided here for Sierra Leone may offer some generalizable insight into the scope of the burden of musculoskeletal disease for low- and middle-income countries, especially in Sub-Saharan Africa, and provide concrete evidence that musculoskeletal health should be included in the global health discussion. However, there may be important differences across countries in this region, and further study to elucidate these differences seems critical given the large burden of disease and the limited resources available in these regions to manage it.

Head injury--a neglected public health problem: a four-month prospective study at Jimma University Specialized Hospital, Ethiopia

Background

Trauma, especially head trauma, is an expanding major public health problem and the leading cause of death of the young and productive part of the world's population. Research is mainly done in high-income countries where only a small proportion of the worldwide fatalities occur. The intention of this study was to analyze head injury in a setting where most patients in low- and middle-income countries receive treatment, a referral hospital with general but no neurosurgical service like Jimma University Specialized Hospital. The study aims to provide surgeons, hospital managers and health planners working in similar set-ups with baseline information for further investigation and prevention programs intending to reduce the burden of head injury.

Methods

All head injury patients presented to Jimma University Specialized Hospital between March and June 2010 were included in this prospective research. Epidemiological, clinical and management data were collected for the study.

Results

Out of 52 patients, 47 were males. The median age was 20.0 years (SD=13.3). Fights (n=20, 38.5%) and road traffic accidents (n=19, 36.5%) were the most common causes of head injury. Half of the patients sustained mild and 36.5% sustained severe head injury. The initial GCS had a significant correlation with the outcome. The mortality rate was 21.2%. Of all patients 76.9% were managed conservatively.

Conclusion

Prevention of road traffic accidents and improvement of conservative care were identified as major methods to reduce the burden of head injury in a set-up similar to Jimma. Further studies on head injury patients in low-income countries should be done.

The socioeconomic inequality in traffic-related disability among Chinese adults: the application of concentration index

Traffic crashes have become the fifth leading cause of burden of diseases and injuries in China. More importantly, it may further aggravate the degree of health inequality among Chinese population, which is still under-investigated. Based on a nationally representative data, we calculated the concentration index (CI) to measure the socioeconomic inequality in traffic-related disability (TRD), and decomposed CI into potential sources of the inequality. Results show that more than 1.5 million Chinese adults were disabled by traffic crashes and the adults with financial disadvantage bear disproportionately heavier burden of TRD. Besides, strategies of reducing income inequality and protecting the safety of poor road users, are of great importance. Residence appears to counteract the socioeconomic inequality in TRD, however, it does not necessarily come to an optimistic conclusion. In addition to the worrying income gap between rural and urban areas, other possible mechanisms, e.g. the low level of post-crash medical resources in rural area, need further studies. China is one of the developing countries undergoing fast motorization and our findings could provide other countries in similar context with some insights about how to maintain socioeconomic equality in road safety.

Traumatic injuries in developing countries: report from a nationwide cross-sectional survey of Sierra Leone

OBJECTIVE

To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country.

DESIGN

A randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012.

SETTING

Sierra Leone, Africa.

PARTICIPANTS

Three thousand seven hundred fifty randomly selected participants throughout Sierra Leone.

MAIN OUTCOME MEASURES

Mechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures.

RESULTS

Data were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries).

CONCLUSIONS

This study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the world's poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas.

The effect of road and environmental characteristics on pedestrian hit-and-run accidents in Ghana

The number of pedestrians who have died as a result of being hit by vehicles has increased in recent years, in addition to vehicle passenger deaths. Many pedestrians who were involved in road traffic accident died as a result of the driver leaving the pedestrian who was struck unattended at the scene of the accident. This paper seeks to determine the effect of road and environmental characteristics on pedestrian hit-and-run accidents in Ghana. Using pedestrian accident data extracted from the National Road Traffic Accident Database at the Building and Road Research Institute (BRRI) of the Council for Scientific and Industrial Research (CSIR), Ghana, a binary logit model was employed in the analysis. The results from the estimated model indicate that fatal accidents, unclear weather, nighttime conditions, and straight and flat road sections without medians and junctions significantly increase the likelihood that the vehicle driver will leave the scene after hitting a pedestrian. Thus, integrating median separation and speed humps into road design and construction and installing street lights will help to curb the problem of pedestrian hit-and-run accidents in Ghana.

Hospital-based injury data from level III institution in Cameroon: retrospective analysis of the present registration system

BACKGROUND

Data on the epidemiology of trauma in Cameroon are scarce. Presently, hospital records are still used as a primary source of injury data. It has been shown that trauma registries could play a key role in providing basic data on trauma. Our goal is to review the present emergency ward records for completeness of data and provide an overview of injuries in the city of Limbe and the surrounding area in the Southwest Region of Cameroon prior to the institution of a formal registration system.

METHODS

A retrospective review of Emergency Ward logs in Limbe Hospital was conducted over one year. Records for all patients over 15 years of age were reviewed for 14 data points considered to be essential to a basic trauma registry. Completeness of records was assessed and a descriptive analysis of patterns and trends of trauma was performed.

RESULTS

Injury-related conditions represent 27% of all registered admissions in the casualty department. Information on age, sex and mechanism of injury was lacking in 22% of cases. Information on vital signs was present in 2% (respiratory rate) to 12% (blood pressure on admission) of records. Patient disposition (admission, transfer, discharge, or death) was available 42% of the time, whilst location of injury was found in 84% of records. Road traffic injury was the most frequently recorded mechanism (36%), with the type of vehicle specified in 54% and the type of collision in only 22% of cases. Intentional injuries were the second most frequent mechanism at 23%.

CONCLUSION

The frequency of trauma found in this context argues for further prevention and treatment efforts. The institution of a formal registration system will improve the completeness of data and lead to increased ability to evaluate the severity and subsequent public health implications of injury in this region.

Identifying barriers to emergency care services

OBJECTIVE

This paper aims to present a review of published evidence of barriers to emergency care, with attention towards both financial and other barriers.

METHOD

With the keywords (financial) accessibility, barriers and emergency care services, citations in PubMed were searched and further selected in the context of the objective of this article.

RESULTS

Forty articles, published over a period of 15 years, showed evidence of significant barriers to emergency care. These barriers often tend to persist, despite the fact that the evidence was published many years ago. Several publications stressed the importance of the financial barriers in foregoing or delaying potentially life-saving emergency services, both in poor and rich countries. Other publications report non-financial barriers that prevent patients in need of emergency care (pre-hospital and in-patient care) from seeking care, from arriving in the proper emergency department without undue delay or from receiving proper treatment when they do arrive in these departments.

CONCLUSION

It is clear that timely access to life-saving and disability-preventing emergency care is problematic in many settings. Yet, low-cost measures can likely be taken to significantly reduce these barriers. It is time to make an inventory of these measures and to implement the most cost-effective ones worldwide.

Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

BACKGROUND

Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index.

METHODS

The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care.

FINDINGS

Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care.

INTERPRETATION

Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health.

FUNDING

Surgeons OverSeas, Thompson Family Foundation.

Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country

Introduction:

Traumatic brain injuries (TBI) are steadily increasing and are a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries. Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India. In the present study, we describe our experience of resource utilization in the management of TBI in a critical care unit (CCU) from a rural setup.

Materials and Methods:

All consecutive patients who were admitted from January 2007 to December 2009 in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome.

Results:

The total duration (days) of hospital stay was 8.96±6.16 days and a median of 8 days, and CCU stay was 3.77±6.34 days with a median of 2 days. No deaths occurred with mild head injury. A total of 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, odds ratio (OR) 1.032 [95% confidence interval (CI) 0.351–3.03], so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954–1.00). The severity of head injury (mild, moderate, and severe) and CCU stay parameters had significant difference with risk of death [OR, 3.22 (95% CI, 2.49–4.16) and OR, 2.50 (95% CI, 1.9–3.2)].

Conclusions:

Apparently it seems possible to use the existing health care structures in rural areas to improve trauma care. It becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard, there is a need to compare with the reference group to further support the evidence.

Snapshot of surgical activity in rural Ethiopia: is enough being done?

BACKGROUND

Surgical conditions are responsible for a significant burden of the disease prevalence in sub-Saharan Africa. However, there is a paucity of data surrounding the amount and availability of surgical care. Few surveys exist that document current rates of surgical activity in the low-income setting, and most figures rely on the country estimates. We aim to document accurately the rates of surgery at the district level.

METHODS

We performed a retrospective survey of surgical activity in 10 hospitals in the Southern Nation and Nationalities Peoples' Region of Ethiopia using a standardized data collection form. We also performed structured interviews with hospital directors.

RESULTS

Surgical output varied across the hospitals from 56 to 421 operations per year per 100,000 catchment population. The most commonly performed operation was cesarean section (29% of major procedures). Emergency surgery accounted for 55% of operations, with the most frequent emergency operation being cesarean section. The overall cesarean section rate was alarmingly low at 0.6%. There are only 76 health workers that are providing a surgical service to this sample population of 12.9 million people.

CONCLUSIONS

The rates of surgery found here were very low, consistent with the huge shortage of health workers providing a surgical service. The low cesarean section rate indicates that there is a large unmet surgical disease burden at the population level, and more comprehensive surveys are required to investigate this further. The most important steps to tackle the problem of deficiencies in global surgery are to increase access to surgical care and the surgical workforce capacity.

An estimate of the number of lives that could be saved through improvements in trauma care globally

BACKGROUND

Reducing the global burden of injury requires both injury prevention and improved trauma care. We sought to provide an estimate of the number of lives that could be saved by improvements in trauma care, especially in low income and middle income countries.

METHODS

Prior data showed differences in case fatality rates for seriously injured persons (Injury Severity Score ≥ 9) in three separate locations: Seattle, WA (high income; case fatality 35%); Monterrey, Mexico (middle income; case fatality 55%); and Kumasi, Ghana (low income; case fatality 63%). For the present study, total numbers of injury deaths in all countries in different economic strata were obtained from the Global Burden of Disease study. The number of lives that could potentially be saved from improvements in trauma care globally was calculated as the difference in current number of deaths from trauma in low income and middle income countries minus the number of deaths that would have occurred if case fatality rates in these locations were decreased to the case fatality rate in high income countries.

RESULTS

Between 1,730,000 and 1,965,000 lives could be saved in low income and middle income countries if case fatality rates among seriously injured persons could be reduced to those in high income countries. This amounts to 34-38% of all injury deaths.

CONCLUSIONS

A significant number of lives could be saved by improvements in trauma care globally. This is another piece of evidence in support of investment in and greater attention to strengthening trauma care services globally.

Analysis of fatal road traffic crashes in Ghana

The major objective of this study was to identify the risk factors associated with fatal road traffic crashes (RTCs) and to propose remedial measures to address them. Fatal RTC data for the period 2005-2007 in Ghana were analysed using the Micro-computer Accident Analysis Package (MAAP) software. Other transport-related research works were reviewed and incorporated in the article. The study showed that pedestrians accounted for 42% of all road traffic fatalities and nearly one-third (33%) of these crashes occurred during the early night-time hours. Children alone constituted almost one-third of all pedestrian fatalities. The occupants of goods vehicles accounted for 12% of all road traffic fatalities although goods vehicles constitute just about 9% of the total motor vehicle population in Ghana. Pedestrians, especially children bear a disproportionately high share of road traffic fatalities in Ghana. The risk of being killed as a pedestrian in traffic is exacerbated during night time. Excessive vehicular speeds, inappropriate use of goods vehicles for passenger transport, excessive loading and inadequate trauma care are the key contributory risk factors to the high number of road traffic fatalities. Concerted efforts spanning education, engineering, enforcement and trauma care are needed to stem the rise in fatal crashes in Ghana.

Disparities in injury mortality between Uganda and the United States: comparative analysis of a neglected disease

Background

The burden of global injury-related deaths predominantly affects developing countries, which have little infrastructure to evaluate these disparities. We describe injury-related mortality patterns in Kampala, Uganda and compare them with data from the United States and San Francisco (SF), California.

Methods

We created a database in Kampala of deaths recorded by the City Mortuary, the Mulago Hospital Mortuary, and the Uganda Ministry of Health from July to December 2007. We analyzed the rate and odds ratios and compared them to data from the U.S. Centers for Disease Control and Prevention and the California Department of Public Health.

Results

In Kampala, 25% of all deaths were due to injuries (812/3303) versus 6% in SF and 7% in the United States. The odds of dying of injury in Kampala were 5.0 times higher than in SF and 4.2 times higher than in the United States. Age-standardized death rates indicate a 93% greater risk of dying from injury in Kampala than in SF. The mean age was lower in Kampala than in SF (29 vs. 44 years). The adult injury death rate (rate ratio, or RR) was higher in Kampala than in SF (2.3) or the United States (1.5). Head/neck injury was reported in 65% of injury deaths in Kampala compared to 34% in SF [odds ratio (OR) 3.7] and 28% in the US (OR 4.8).

Conclusions

Urban injury-related mortality is significantly higher in Uganda than in the United States. Injury preferentially affects adults in the prime of their economically productive years. These findings serve as a call for stronger injury prevention and control policies in Uganda.

Epidemiology of child injuries in Uganda: challenges for health policy

Globally, 90% of road crash deaths occur in the developing world. Children in Africa bear the major part of this burden, with the highest unintentional injury rates in the world. Our study aims to better understand injury patterns among children living in Kampala, Uganda and provide evidence that injuries are significant in child health. Trauma registry records of injured children seen at Mulago Hospital in Kampala were analysed. Data were collected when patients were seen initially and included patient condition, demographics, clinical variables, cause, severity, as measured by the Kampala trauma score, and location of injury. Outcomes were captured on discharge from the casualty department and at two weeks for admitted patients. From August 2004 to August 2005, 872 injury visits for children <18 years old were recorded. The mean age was 11 years (95% CI 10.9-11.6); 68% (95% CI 65-72%) were males; 64% were treated in casualty and discharged; 35% were admitted. The most common causes were traffic crashes (34%), falls (18%) and violence (15%). Most children (87%) were mildly injured; 1% severely injured. By two weeks, 6% of the patients admitted for injuries had died and, of these morbidities, 16% had severe injuries, 63% had moderate injuries and 21% had mild injuries. We concluded that, in Kampala, children bear a large burden of injury from preventable causes. Deaths in low severity patients highlight the need for improvements in facility based care. Further studies are necessary to capture overall child injury mortality and to measure chronic morbidity owing to sequelae of injuries.

The relationship of pedestrian injuries to socioeconomic characteristics in a large Southern California County

OBJECTIVES

The goal of this study is to explore the relationship between pedestrian injuries and socioeconomic characteristics.

METHODS

Pedestrian collisions were identified in the data of the California Statewide Integrated Traffic Records System (SWITRS), which is assembled from police crash reports by the California Highway Patrol Information Services Unit. Four thousand crashes were identified and geocoded within the census tracts in a county population of 2,846,289 over a 5-year period. Population and population characteristics for census tracts were obtained from the 2000 U.S. Census.

RESULTS

The percentage of the population living in households with low income (less than 185% of the federal poverty level) was the strongest predictor of pedestrian injuries. One fourth of census tracts had less than 8.7 percent of residents with low income and averaged 11 per 100,000 pedestrian crashes annually. One fourth of the census tracts had more than 32.2 percent of residents with low income and an average of 44 pedestrian crashes per 100,000 annually. Negative binomial regression showed that with each 1 percent increase in the percentage of residents with low income was associated with a 2.8 percent increase in pedestrian crashes. The percentage of residents age 14 years or less, adult residents who had not completed high school, residents who spoke English less than "very well" and spoke another language at home, and the population density were each associated with a higher frequency of pedestrian crashes. However, when low income was added to these 4 regression models, the relationship between low income and pedestrian crashes increased.

CONCLUSIONS

Our study showed that pedestrian crashes are 4 times more frequent in poor neighborhoods and that neither age of the population, education, English language fluency, nor population density explained the effect of poverty.

Current patterns of prehospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training program

BACKGROUND

Uganda currently has no organized prehospital emergency system. We sought to measure the current burden of injury seen by lay people in Kampala, Uganda and to determine the feasibility of a lay first-responder training program.

METHODS

We conducted a cross-sectional survey of current prehospital care providers in Kampala: police officers, minibus taxi drivers, and Local Council officials, and collected data on types and frequencies of emergencies witnessed, barriers to aid provision, history of training, and current availability of first-aid supplies. A context-appropriate course on basic first-aid for trauma was designed and implemented. We measured changes in trainees' fund of knowledge before and after training.

RESULTS

A total of 309 lay people participated in the study, and during the previous 6 months saw 18 traumatic emergencies each; 39% saw an injury-related death. The most common injury mechanisms were road crashes, assault, and burns. In these cases, 90% of trainees provided some aid, most commonly lifting (82%) or transport (76%). Fifty-two percent of trainees had previous first-aid training, 44% had some access to equipment, and 32% had ever purchased a first-aid kit. Before training, participants answered 45% of test questions correctly (mean %) and this increased to 86% after training (p < 0.0001).

CONCLUSIONS

Lay people witness many emergencies and deaths in Kampala, Uganda and provide much needed care but are ill-prepared to do so. A context-appropriate prehospital trauma care course can be developed and improve lay people's knowledge of basic trauma care. The effectiveness of such a training program needs to be evaluated prospectively.

Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy

Background

Despite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality.

Aim

To estimate the epidemiology of the injury seen in patients presenting to the government hospital in Kampala, the capital city of Uganda.

Methods

A secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005.

Results

From 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance.

Conclusions

Road traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development.