Level of knowledge and practice of female healthcare providers about early detection methods of breast cancer at Debre Tabor Comprehensive Specialised Hospital: a cross-sectional study

Background: Despite the higher mortality rate of breast cancer in low and middle-income countries, the practice of early detection methods is low and the majority of the patients presenting at an advanced stage of the disease need palliative care with low survival rates. Although healthcare providers are the key for practicing early detection methods of breast cancer for themselves and their clients, little is known about their knowledge and practice of early detection methods of breast cancer in Northcentral Ethiopia.

Methods: An institution-based cross-sectional study was conducted among female healthcare providers at Debre Tabor Comprehensive Specialised Hospital. Data were collected using a structured self-administered questionnaire. The data were analysed using SPSS version 23. Descriptive statistics were used to describe the socio-demographic information of participants. Binary and multivariable logistic regression with adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify factors associated with the outcome variable. Statistical significance was declared at p 2 years (AOR = 3.2; 95% CI: 1.72, 5.29), history of any breast problem (AOR = 1.4; 95% CI: 1.02, 2.37), family history of breast cancer (AOR = 4.0; 95% CI: 2.58, 15.84), having good knowledge (AOR = 2.9; 95% CI: 1.3, 6.52) and history of comorbidities (AOR = 1.09; 95% CI: 1.09, 3.59) were the factors associated with the practice of breast self-examination.

Conclusion: Our study found that the knowledge and practice of breast cancer early detection methods was low in the study setting. Only less than half of female healthcare providers practiced regular breast self-examination, which suggests the need to provide training for healthcare providers to fill the gap and to promote early detection of breast cancer cases.

Fixation of intertrochanteric femur fractures using the SIGN intramedullary nail augmented by a lateral plate in a resource-limited setting without intraoperative fluoroscopy: assessment of functional outcomes at one-year follow-up at Juba Teaching Hospital

Objectives:
The incidence of hip fracture is high and increasing globally due to an aging population. Morbidity and mortality from these injuries are high at baseline and worse without prompt surgical treatment to facilitate early mobilization. Due to resource constraints, surgeons in low-income countries often must adapt available materials to meet these surgical needs. The objective of this study is to assess functional outcomes after surgical fixation of intertrochanteric femur fractures with the Surgical Implant Generation Network (SIGN) intramedullary nail augmented by a lateral SIGN plate.

Design:
Prospective case series

Setting:
Juba Teaching Hospital, Tertiary Referral Hospital for South Sudan

Participants:
Adult patients with intertrochanteric hip fractures

Intervention:
SIGN nail augmented by a lateral plate

Main Outcome Measurements:
Primary outcome was hip function as measured by a modified Harris Hip Score (mHHS) at 1-year after surgery. Secondary endpoints were the occurrence of reoperation or infection at 1-year after surgery.

Results:
Thirty patients were included, 16 (53%) men and 14 (47%) women, with a mean age of 62 years. Fractures were classified as AO/OTA Type 31A1 in 12 (40%) patients, 31A2 in 15 (50%) patients, and 31A3 in 3 (10%) patients. Mean mHHS at 1-year was 75.10 ± 21.2 with 76% categorized as excellent or good scores. There was 1 (3%) infection and 2 (7%) reoperations.

Conclusions:
The SIGN nail augmented by a lateral plate achieved good or excellent hip function in the majority of patients with intertrochanteric hip fractures. This may be a suitable alternative to conventional implants for hip fracture patients in low-resource settings to allow mobilization.

Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.

Magnitude, Factors Associated with Cesarean Delivery and Its Appropriateness

Inappropriate use of CS can have profoundly negative consequences for women and the broader community. A recent meeting of the International Confederation of Midwifes, the International Federation of Gynecologists and Obstetrics and the Gates Foundation to discuss the impact of rising CS rates on maternal and infant mortality in LMICs highlights the international importance of the issue. Knowledge of CS determinants is a first step in the effort to define strategies to reduce unnecessary CSs. Previous studies showed that the main reasons for performing CS are clinical factors. However, non-clinical factors such as demographic, health system factors, organizational variables were overlooked determinants that best predicted which women have a higher risk of CS.

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

Background
Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

Conclusion
The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

Undergraduate Surgical Education: a Global Perspective

Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.

Effectiveness of an mHealth system on access to eye health services in Kenya: a cluster-randomised controlled trial

Background
There is limited access to eye health services in many low-income and middle-income populations. We aimed to assess the effectiveness in increasing service utilisation of the Peek Community Eye Health (Peek CEH) system, a smartphone-based referral system comprising decision support algorithms (Peek Community Screening app), SMS reminders, and real-time reporting.

Methods
In this cluster-randomised controlled trial of eye health in Kenya, community unit clusters were defined as one health centre and its catchment population. Clusters were randomly allocated (1:1) to receive Peek CEH and referral (intervention group) or standard care via periodic health centre-based outreach clinics and onward referral (control group). Individuals in the intervention group were assessed at home by screeners and those referred were asked to present for triage assessment in a central location. They received regular SMS reminders. In both groups, community sensitisation was done followed by a triage clinic at the cluster health centre 4 weeks after sensitisation. During triage, individuals in both groups were assessed and treated and, if necessary, referred to a specific hospital. Individuals in the intervention group received further SMS reminders. The primary outcome was the mean attendance rate (the number of people per 10 000 population) at triage of those with confirmed eye conditions, as assessed at 4 weeks after sensitisation in the intention-to-treat population. We estimated the intervention effect using a Student’s t-test on cluster-level rates. This trial is registered with Pan African Clinical Trial Registry, number 201807329096632.

Findings
Between Nov 26, 2018, and June 7, 2019, of the 85 community units in Trans Nzoia County, Kenya, 49 were excluded. We randomly allocated 18 community units each to the intervention group (68 348 individuals) and the control group (60 243 individuals). 9387 individuals from the intervention group and 3070 from the control group attended triage assessment. The mean attendance rate at triage by individuals with eye problems was 1429 (92% CI 1228–1629) in the intervention group and 522 (418–625) in the control group (rate difference 906 per 10 000 [95% CI 689–1124; p<0·0001]).

Interpretation
The Peek CEH system increased primary care attendance by people with eye problems compared with standard approaches, indicating the potential of this mobile health package to increase service uptake and guide appropriate task sharing.

Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers

Background
Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services.

Methods
Between June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers.

Results
Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow.

Conclusion
Findings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge.

Feasibility of establishing an infant hearing screening program and measuring hearing loss among infants at a regional referral hospital in south western Uganda

Introduction
Despite the high burden of hearing loss (HL) globaly, most countries in resource limited settings lack infant hearing screening programs(IHS) for early HL detection. We examined the feasibility of establishing an IHS program in this setting, and in this pilot program measured the prevalence of infant hearing loss (IHL) and described the characteristics of the infants with HL.

Methods
We assessed feasibility of establishing an IHS program at a regional referral hospital in south-western Uganda. We recruited infants aged 1 day to 3 months and performed a three-staged screening. At stage 1, we used Transient Evoked Oto-acoustic Emissions (TEOAEs), at stage 2 we repeated TEOAEs for infants who failed TEOAEs at stage 1 and at stage 3, we conducted Automated brainstem responses(ABRs) for those who failed stage 2. IHL was present if they failed an ABR at 35dBHL.

Results
We screened 401 infants, mean age was 7.2 days (SD = 7.1). 74.6% (299 of 401) passed stage 1, the rest (25.4% or 102 of 401) were referred for stage 2. Of those referred (n = 102), only 34.3% (35 of 102) returned for stage 2 screening. About 14.3% (5/35) failed the repeat TEOAEs in at least one ear. At stage 3, 80% (4 of 5) failed the ABR screening in at least one ear, while 25% (n = 1) failed the test bilaterally. Among the 334 infants that completed the staged screening, the prevalence of IHL was 4/334 or 12 per 1000. Risk factors to IHL were Newborn Special Care Unit (NSCU) admission, gentamycin or oxygen therapy and prematurity.

Conclusions
IHS program establishment in a resource limited setting is feasible. Preliminary data indicate a high prevalence of IHL. Targeted screening of infants at high risk may be a more realistic and sustainable initial step towards establishing IHS program s in a developing country like Uganda.

Synthesizing postpartum care pathways, facilitators, and barriers for women after cesarean section: a qualitative analysis from rural Rwanda

Background
In low- and middle-income countries (LMICs), c-section is the most commonly performed operation, and surgical site infection (SSI) is the most common post-operative complication following all surgical procedures performed. Whilst multiple interventions have been rolled out to address high SSI rates, strategies for optimal care of patients at risk of developing SSIs need to include an understanding of the general care seeking behaviors, facilitators, and barriers among high-risk groups, including mothers delivering via c-section. This study explores the healthcare experiences of women who delivered by c-section section, from giving birth through recovery, and their associated decision-making, perceptions of care, and social and financial supports.

Methods
We conducted protocol-guided interviews in rural Kirehe District, Rwanda with twenty-five mothers who delivered by c-section at Kirehe District Hospital between February-April 2018, exploring their experience with delivery, hospitalization, recovery, and complications. Coded interviews were analyzed using the Grounded Theory approach to identify emergent themes. Thematic saturation was achieved.

Results
Overall, women largely followed the tiered referral system, as it was designed. A majority faced financial barriers to returning to care, and a majority were not able to describe the reason for their c-section, the complications experienced, or the treatment prescribed. We constructed a process map to summarize key steps where interventions should be designed to promote facilitators, to reduce barriers, and to identify and target the women being diverted from this designated path.

Conclusions
Understanding the existing healthcare pathway and the associated facilitators and barriers among postpartum women is critical to designing appropriate interventions that properly serve their needs. Our findings strongly suggest that moving or complimenting post-operative wound assessments from the health center into home-based care, and ensuring unified messaging around c-section indications, care, and complications at the community-level are two of the areas that may improve utilization of existing healthcare infrastructure for women who deliver by c-section in rural districts in Rwanda.