Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward

This chapter is based on persons with physical disabilities in Africa, their challenges, and how it affects their health-seeking behaviors. We noticed that physical challenge has a substantial long-term adverse effect on one’s ability to carry out normal day-to-day activities. Both the causes and the consequences of physical disability vary throughout the world, especially in Africa. Environmental, technical, and attitudinal barriers and consequent social exclusion reduce the opportunities for physically challenged persons to contribute productively to the household and the community and further increase the risk of falling into poverty and poor healthcare services. The inability of the physically challenged persons to perceive the lack of points of interest of government has intensified to make significant recommendations and possible solutions. This is appalling because the rate to which a community provides and funds restoration is a way of grading how much interest it has, and importance it connects to the quality of life of its citizens. We advocate and recommend swift actions and disability inclusiveness to accommodate persons with physical disabilities in Africa for them to have a good perception of life.

Postoperative outcomes associated with surgical care for women in Africa: an international risk-adjusted analysis of prospective observational cohorts

Background
Improving women’s health is a critical component of the sustainable development goals. Although obstetric outcomes in Africa have received significant focus, non-obstetric surgical outcomes for women in Africa remain under-examined.

Methods
We did a secondary analysis of the African Surgical Outcomes Study (ASOS) and International Surgical Outcomes Study (ISOS), two 7-day prospective observational cohort studies of outcomes after adult inpatient surgery. This sub-study focuses specifically on the analysis of the female, elective, non-obstetric, non-gynaecological surgical data collected during these two large multicentre studies. The African data from both cohorts are compared with international (non-African) outcomes in a risk-adjusted logistic regression analysis using a generalised linear mixed-effects model. The primary outcome was severe postoperative complications including in-hospital mortality in Africa compared with non-African outcomes.

Results
A total of 1698 African participants and 18 449 international participants met the inclusion criteria. The African cohort were younger than the international cohort with a lower preoperative risk profile. Severe complications occurred in 48 (2.9%) of 1671, and 431 (2.3%) of 18 449 patients in the African and international cohorts, respectively, with in-hospital mortality after severe complications of 23/48 (47.9%) in Africa and 78/431 (18.1%) internationally. Women in Africa had an adjusted odds ratio of 2.06 (95% confidence interval, 1.17–3.62; P=0.012) of developing a severe postoperative complication after elective non-obstetric, non-gynaecological surgery, compared with the international cohort.

Conclusions
Women in Africa have double the risk adjusted odds of severe postoperative complications (including in-hospital mortality) after elective non-obstetric, non-gynaecological surgery compared with the international incidence.

Chest trauma epidemiology and emergency department management in a tertiary teaching hospital in Kigali, Rwanda

Introduction
Chest trauma is a major contributor to injury morbidity and mortality, and understanding trends is a crucial part of addressing this burden in low- and middle-income countries. This study reports the characteristics and emergency department (ED) management of chest trauma patients presenting to Rwanda’s national teaching hospital in Kigali.

Methods
This descriptive analysis included a convenience sample of patients presenting to a single tertiary hospital ED with chest trauma from June to December 2017. Demographic data were collected as well as injury mechanism, thoracic and associated injuries, types of imaging obtained, and treatments performed. Chart review was conducted seven days post-admission to follow up on outcomes and additional diagnoses and interventions. Incidences were calculated with Microsoft Excel.

Results
Among the 62 patients included in this study, 74% were male, and mean age was 35 years. Most patients were injured in road traffic crashes (RTCs) (68%). Common chest injuries included lung contusions (79% of cases), rib fractures (44%), and pneumothoraces (37%). Head trauma was a frequent concurrent extra-thoracic injury (61%). Diagnostic imaging primarily included E-FAST ultrasound (92%) and chest x-ray (98%). The most common therapies included painkillers (100%), intravenous fluids (89%), and non-invasive oxygen (63%), while 29% underwent invasive intervention in the form of thoracostomy. The majority of patients were admitted (81%). Pneumonia was the most common complication to occur in the first seven days (32% of admitted patients). Ultimately, 40% of patients were discharged home within seven days of presentation, 50% remained hospitalized, and 5% died.

Conclusion
This study on the epidemiology of chest trauma in Rwanda can guide injury prevention and medical training priorities. Efforts should target prevention in young males and those involved in RTCs. ED physicians in Rwanda need to be prepared to diagnose and treat a variety of chest injuries with invasive and noninvasive means.

State of African neurosurgical education: a protocol for an analysis of publicly available curricula

Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.

Nutritional intake in acute care surgery patients in Kigali, Rwanda- A single institution descriptive analysis

INTRODUCTION: Nutrition is essential for health and healing, especially in the perioperative period. However, little is known about the nutritional intake of hospitalized patients in low and middle-income countries.
This paper aimed to characterize the composition and quantity of food in acute care surgery patients at a tertiary referral hospital in Rwanda.

METHODS: Acute care surgery patients were queried about nutritional intake during hospitalization from May 21, 2018, to June 3, 2018, for 100 patient days. Calorie and protein intake were estimated and compared to standards for an average Rwandan adult.
RESULTS: Median daily calorie intake was 1472 kcal/day (Interquartile range (IQR): 662, 2116). The median daily protein intake was 45.99 g (IQR: 24.38, 70.22). Assuming a calorie need of 25 kcal/kg/day and a protein need of 1g/kg/day, this is 98.1% of the estimated daily calorie needs and 76.7% of estimated daily protein needs. Estimating higher energy needs for a surgical patient, the daily intake is 70.0-81.9% of calorie needs and 51.1-63.9% of protein needs.

CONCLUSION: Overall, the calorie and protein intake for the average Rwandan acute care surgery patient were low compared to the needs of a 60 kg surgical patient. More education and accessibility to high-quality foods are needed to ensure adequate nutrition in the postoperative period to optimize clinical outcomes.

A collaboration to improve perioperative acute pain care at the University Teaching Hospital of Butare, Rwanda

BACKGROUND: A perioperative acute pain care program integrating standardized assessment and treatment forms into pain care was developed and implemented at an urban hospital in Rwanda through a collaboration between Rwandan and Canadian experts. This study evaluated the perioperative acute pain care program using a quality improvement lens.

METHODS: Using the Model for Improvement: Plan, Do, Study, Act (PDSA) cycle, a mixed methods evaluation was performed. Over one year, 519 randomized patient chart audits were conducted and analyzed through control charts. Through purposeful sampling, focus groups comprised ofsurgeons and nurses (N=34) involved in pain care in surgery, obstetrics, and anesthesiology were performed and analyzed via thematic coding.

RESULTS: The average attempted form completion rate across all forms varied monthly between 56-93% (mean=79%; median=81%). Across all forms, both the mean and median total number of errors per form were 12.5. Enablers of form use included improved pain care for patients and feelings of professional satisfaction. Program implementation was challenged by resource constraints, form integration, and health care provider training.

CONCLUSION: Future quality improvement collaborations should identify and address improved pain care while working with local experts to ensure PDSA cycles are continuous, and evidence based.

Rural–urban disparities in caesarean deliveries in sub-Saharan Africa: a multivariate non-linear decomposition modelling of Demographic and Health Survey data

Introduction
Globally, the rate of caesarean deliveries increased from approximately 16.0 million in 2000 to 29.7 million in 2015. In this study, we decomposed the rural–urban disparities in caesarean deliveries in sub-Saharan Africa.

Methods
Data for the study were extracted from the most recent Demographic and Health Surveys of twenty-eight countries in sub-Saharan Africa. We included 160,502 women who had delivered in health facilities within the five years preceding the survey. A multivariate non-linear decomposition model was employed to decompose the rural–urban disparities in caesarean deliveries. The results were presented using coefficients and percentages.

Results
The pooled prevalence of caesarean deliveries in the 28 countries considered in the study was 6.04% (95% CI = 5.21–6.88). Caesarean deliveries’ prevalence was highest in Namibia (16.05%; 95% CI = 14.06–18.04) and lowest in Chad (1.32%; 95% CI = 0.91–1.73). For rural-urban disparities in caesarean delivery, the pooled prevalence of caesarean delivery was higher in urban areas (10.37%; 95% CI = 8.99–11.75) than rural areas (3.78%; 95% CI = 3.17-4.39) across the 28 countries. Approximately 81% of the rural–urban disparities in caesarean deliveries were attributable to the differences in child and maternal characteristics. Hence, if the child and maternal characteristics were levelled, more than half of the rural–urban inequality in caesarean deliveries would be reduced. Wealth index (39.2%), antenatal care attendance (13.4%), parity (12.8%), mother’s educational level (3.5%), and health insurance subscription (3.1%) explained approximately 72% of the rural–urban disparities in caesarean deliveries.

Conclusion
This study shows significant rural–urban disparities in caesarean deliveries, with the disparities being attributable to the differences in child and maternal characteristics: wealth index, parity, antenatal care attendance, mother’s educational level, and health insurance subscription. Policymakers in the included countries could focus and work on improving the socioeconomic status of rural-dwelling women as well as encouraging antenatal care attendance, women’s education, health insurance subscription, and family planning, particularly in rural areas.

Tools for self-management of obstetric fistula in low- and middle-income countries: a qualitative study exploring pre-implementation barriers and facilitators among global stakeholders

Background: Obstetric fistula, a debilitating maternal morbidity, occurs in contexts with poor access to and quality of emergency obstetric care, predominantly in sub-Saharan Africa. As many as two million women and girls suffer from fistula, which results in urinary incontinence, vulnerability to stigma for women and families, and economic consequences for the household and the healthcare system. Surgical repair, the gold standard for treatment, remains inaccessible to many and success is not guaranteed. Non-surgical, user-controlled fistula management options are not readily accessible, although some technologies, like insertable devices, have been found to have some level of feasibility and acceptability and provide short-term control over incontinence. As evidence for the effectiveness of tools to support self-management grows, the determinants of their implementation within various contexts remain unknown. The purpose of this qualitative study was to explore with key stakeholders, prior to implementation, those factors that could influence successful implementation of an innovation for self-management of obstetric fistula in a LMIC.

Methods: Stakeholders were purposefully identified from sectors that address the needs of women with obstetric fistula in sub-Saharan Africa: clinical care, academia, international health organizations, civil society, and government. Twenty-one key stakeholders were interviewed about their perceptions of innovations for fistula self-management and their implementation. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis of transcripts from recorded interviews. Analyses were carried out within Nvivo v.12. Deductive coding focused on constructs within the CFIR, then inductive coding identified additional constructs relevant for implementation.

Results: Potential facilitators to implementation included a clear tension for change for low-cost, accessible innovations for self-management and a relative advantage over existing tools. The development of partnerships and identification of champions could also support implementation. Barriers included the lack of evidence identifying the optimal beneficiary and the need for educational strategies that encourage acceptability among clinical providers. Inductive coding revealed an additional relevant construct of sustainability.

Conclusions: Effectiveness and implementation of non-surgical tools for fistula self-management should be further examined in LMICs. Future research could inform comprehensive fistula care to reduce vulnerability to stigma and improve quality of life.

International pediatric surgery partnerships in sub-Saharan Africa: a scoping literature review

Background
Sub-Saharan Africa (SSA) faces a critical shortage of pediatric surgical providers. International partnerships can play an important role in pediatric surgical capacity building but must be ethical and sustainable.

Objective
The purpose of this study is to perform a scoping literature review of international pediatric surgery partnerships in SSA from 2009 to 2019. We aim to categorize and critically assess past partnerships to aid in future capacity-building efforts.

Methods
We performed a scoping literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. We searched the PubMed and Embase databases for articles published from 2009 to 2019 using 24 keywords. Articles were selected according to inclusion criteria and assessed by two readers. Descriptive analyses of the data collected were conducted in Excel.

Results
A total of 2376 articles were identified. After duplicates were removed, 405 articles were screened. In total, 83 articles were assessed for eligibility, and 62 were included in the review. The most common partnership category was short-term surgical trip (28 articles, 45%). A total of 35 articles (56%) included education of host country providers as part of the partnership. Only 45% of partnerships included follow-up care, and 50% included postoperative outcomes when applicable.

Conclusions
To increase sustainability, more partnerships must include education of local health-care providers, and short-term surgical trips must be integrated into long-term partnerships. More partnerships need to report postoperative outcomes and ensure follow-up care. Educating peri-operative providers, training general surgeons in common pediatric procedures, and increasing telehealth use are other goals for future partnerships.

Telesurgery’s potential role in improving surgical access in Africa

An estimated five billion people worldwide lack access to surgical care, while LMICs including African nations require an additional 143 million life-saving surgical procedures each year.African hospitals are under-resourced and understaffed, causing global attention to be focused on improving surgical access in the continent. The African continent saw its first telesurgery application when the United States Army Special Operations Forces in Somalia used augmented reality to stabilize lifethreatening injuries.Various studies have been conducted since the first telesurgery implementation in 2001 to further optimize its application.In context of a relative shortage of healthcare resources and personnel telesurgery can considerably improve quality and access to surgical services in Africa.telesurgery can provide remote African regions with access to knowledge and tools that were previously unavailable, driving innovative research and professional growth of surgeons in the region.At the same time, telesurgery allows less trained surgeons in remote areas with lower social determinants of health, such as access, to achieve better health outcomes. However, lack of stable internet access, expensive equipment costs combined with low expenditure on healthcare limits expansive utilization of telesurgery in Africa. Regional and international policies aimed at overcoming these obstacles can improve access, optimize surgical care and thereby reduce disease burden associated with surgical conditions in Africa.