Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan

Background
Rheumatic heart disease (RHD) remains a leading cause of morbidity and mortality in Sub-Saharan Africa despite widely available preventive therapies such as prophylactic benzathine penicillin G (BPG). In this study, we sought to characterize facilitators and barriers to optimal RHD treatment with BPG in Sudan.

Methods
We conducted a mixed-methods study, collecting survey data from 397 patients who were enrolled in a national RHD registry between July and November 2017. The cross-sectional surveys included information on demographics, healthcare access, and patient perspectives on treatment barriers and facilitators. Factors associated with increased likelihood of RHD treatment adherence to prophylactic BPG were assessed by using adjusted logistic regression. These data were enhanced by focus group discussions with 20 participants, to further explore health system factors impacting RHD care.

Results
Our quantitative analysis revealed that only 32% of the study cohort reported optimal prophylaxis adherence. Younger age, reduced primary RHD healthcare facility wait time, perception of adequate health facility staffing, increased treatment costs, and high patient knowledge about RHD were significantly associated with increased odds of treatment adherence. Qualitative data revealed significant barriers to RHD treatment arising from health services factors at the health system level, including lack of access due to inadequate healthcare staffing, lack of faith in local healthcare systems, poor ancillary services, and patient lack of understanding of disease. Facilitators of RHD treatment included strong interpersonal support.

Conclusions
Multiple patient and system-level barriers to RHD prophylaxis adherence were identified in Khartoum, Sudan. These included patient self-efficacy and participant perception of healthcare facility quality. Strengthening local health system infrastructure, while enhancing RHD patient education, may help to improve treatment adherence in this vulnerable population.

The impact of the COVID-19 pandemic on international reconstructive collaborations in Africa

Background
The SARS-CoV-2 (COVID-19) pandemic has catalysed a widespread humanitarian crisis in many low- and middle-income countries around the world, with many African nations significantly impacted. The aim of this study was to quantify the impact of the COVID-19 pandemic on the planning and provision of international reconstructive collaborations in Africa.

Methods
An anonymous, 14-question, multiple choice questionnaire was sent to 27 non-governmental organisations who regularly perform reconstructive surgery in Africa. The survey was open to responses for four weeks, closing on the 7th of March 2021. A single reminder was sent out at 2 weeks. The survey covered four key domains: (1) NGO demographics; (2) the impact of COVID-19 on patient follow-up; (3) barriers to the safe provision of international surgical collaborations during COVID-19; (4) the impact of COVID-19 on NGO funding.

Results
A total of ten reconstructive NGOs completed the survey (response rate, 37%). Ethiopia (n = 5) and Tanzania (n = 4) were the countries where most collaborations took place. Plastic, reconstructive and burns surgery was the most common sub-speciality (n = 7). For NGOs that did not have a year-round presence in country (n = 8), only one NGO was able to perform reconstructive surgery in Africa during the pandemic. The most common barrier identified was travel restrictions (within country, n = 8 or country entry-exit, n = 7). Pre-pandemic, 1547 to ≥ 1800 patients received reconstructive surgery on international surgical collaborations. After the outbreak, 70% of NGOs surveyed had treated no patients, with approximately 1405 to ≥ 1640 patients left untreated over the last year.

Conclusions
The COVID-19 pandemic has placed huge pressures on health services and their delivery across the globe. This theme has extended into international surgical collaborations leading to increased unmet surgical needs in low- and middle-income countries.

Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda

Background
Women who deliver via cesarean section (c-section) experience short- and long-term complications that may affect their physical health and their ability to function normally. While physical health outcomes are routinely assessed and monitored, postpartum functional outcomes are not well understood from a patient’s perspective or characterized by clinicians. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30.

Methods
Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities. We computed composite mean scores with a maximum score of 4.0 and scores ≤ 2.0 reflected poor functionality. We assessed functionality with descriptive statistics and logistic regression.

Results
Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30–45 minutes had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, p = 0.037). High income patients had incrementally lower significant odds of poor functionality (aOR = 0.62 for every US$100 increase in monthly income, p = 0.04).

Conclusion
We found a high proportion of poor functionality 30 days post-c-section and while surgery lasting > 30 minutes and experiencing intra-operative complications was associated with poor functionality, a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

Late Diagnosis of Breast Cancer and Associated Factors Among Women Attending Hawassa University Comprehensive and Specialized Hospital Southern Ethiopia

Background; Breast cancer is a significant public health issue in sub-Saharan Africa and the second commonest cancer overall. In Ethiopia, most women present at the late-stage presentation. This is because Ethiopian government gives less attention, and is not well-studied as well. Therefore, it is important to assess delays in diagnosis and treating breast cancer that has been associated with a more advanced stage of the disease and a decrease in patient survival rates.

Objective: To assess the magnitude and associated factors for late diagnosis of breast cancer among women attending Hawassa University Comprehensive Specialized Hospital in Southern Ethiopia.

Methodology: A facility-based cross-sectional study was conducted from December to January 2019. Data were collected from 261 consecutively selected clients based on the arrival of their hospital visit by using a pretested structured questionnaire and checklist. Physicians performed physical examinations and diagnoses. Data was checked for completeness and consistency, and entered into epi data, then exported to SPSS for analysis. Descriptive, Bivariate, and multivariable logistic regression analyses were performed using SPSS Version 25 Statistical Software.

Results: The magnitude of late diagnosis of breast cancer was 86.3%. The woman who had no initial advice for breast biopsy [AOR=5.1, 95% (CI=1.4-18.9)], not sharing the problem to others [AOR=4.7, 95% (CI=1.8-12.2)] and using traditional and faith healers as a first treatment choice [AOR=3.3, 95% (CI=1.2 – 8.8)] were associated with late diagnosis of breast cancer.

Conclusions: The majority of women having breast cancer were diagnosed at a late stage. It needs attention to provide better options of the modern health service, and providing accessible initial advice for breast biopsy, and creating awareness about the benefit of sharing problems with family to improve the health of mothers by early diagnosing and managing the breast cancer.

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

Background
Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme.

Methods
Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach.

Results
Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system.

Conclusions
Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.

Misconceptions About Traumatic Brain Injuries in Five Sub-Saharan African Countries

Background
Traumatic Brain Injury (TBI) remains a significant problem in certain regions of the world but receives little attention despite its enormous burden. This discrepancy could consequently lead to various misconceptions among the general public. This study evaluated misconceptions about TBI in five African countries.

Methods
Data for this cross-sectional study were collected using the Common Misconception about Traumatic Brain Injury (CM-TBI) questionnaire, which was electronically disseminated from January 16 to February 6, 2021. Associations between the percentage of correct answers and independent variables (i.e., sociodemographic characteristics and experience with TBI) were evaluated with the ANOVA test. Additionally, answers to the question items were compared against independent variables using the Chi-Square test. A P-value <0.05 was considered statistically significant.

Results
A total of 817 adults, 50.2% female (n=410), aged 24.3 ± 4.3 years, and majoritarily urban dwellers (94.6%, n=773) responded to the survey. They had received tertiary education (79.2%, n=647) and were from Nigeria (77.7%, n=635). Respondents had few misconceptions (mean correct answers=71.7%, 95% CI=71.0-72.4%) and the amnesia domain had the highest level of misconception (39.3%, 95% CI=37.7-40.8%). Surveyees whose friends had TBI were more knowledgeable about TBI (mean score difference=4.1%, 95% CI=1.2-6.9, P=0.01). Additionally, surveyees whose family members had experienced TBI had a better understanding of brain damage (mean score difference=5.7%, 95% CI=2.1-9.2%, P=0.002) and recovery (mean score difference=4.3%, 95% CI=0.40-8.2%, P=0.03).

Conclusion
This study identified some misconceptions about TBI among young adult Africans. This at-risk population should benefit from targeted education strategies to prevent TBI and reduce TBI patients' stigmatization in Africa.

Cervical Spine Trauma in East Africa: Presentation, Treatment, and Mortality

Background Cervical spine trauma (CST) leads to devastating neurologic injuries. In a cohort of CST patients from a major East Africa referral center, we sought to (a) describe presentation and operative treatment patterns, (b) report predictors of neurologic improvement, and (c) assess predictors of mortality.

Methods A retrospective, cohort study of CST patients presenting to a tertiary hospital in Dar Es Salaam, Tanzania, was performed. Demographic, injury, and operative data were collected. Neurologic exam on admission/discharge and in-hospital mortality were recorded. Univariate/multivariate logistic regression assessed predictors of operative treatment, neurologic improvement, and mortality.

Results Of 101 patients with CST, 25 (24.8%) were treated operatively on a median postadmission day 16.0 (7.0–25.0). Twenty-six patients (25.7%) died, with 3 (12.0%) in the operative cohort and 23 (30.3%) in the nonoperative cohort. The most common fracture pattern was bilateral facet dislocation (26.7%). Posterior cervical laminectomy and fusion and anterior cervical corpectomy were the 2 most common procedures. Undergoing surgery was associated with an injury at the C4–C7 region versus occiput–C3 region (odds ratio [OR] 6.36, 95% confidence interval [CI] 1.71–32.28, P = .011) and an incomplete injury (OR 3.64; 95% CI 1.19–12.25; P = .029). Twelve patients (15.8%) improved neurologically, out of the 76 total patients with a recorded discharge exam. Having a complete injury was associated with increased odds of mortality (OR 11.75, 95% CI 3.29–54.72, P < .001), and longer time from injury to admission was associated with decreased odds of mortality (OR 0.66, 95% CI 0.48–0.85, P = .006). Conclusions Those most likely to undergo surgery had C4–C7 injuries and incomplete spinal cord injuries. The odds of mortality increased with complete spinal cord injuries and shorter time from injury to admission, probably due to more severely injured patients dying early within 24–48 hours of injury. Thus, patients living long enough to present to the hospital may represent a self-selecting population of more stable patients. These results underscore the severity and uniqueness of CST in a less-resourced setting.

Evaluation of Surgical Glove Integrity: Does an African Country Receive Inferior Quality?

In a 2017 study, the incidence of glove perforation in Addis Ababa was found higher than most other publications. This poses a significant threat to both patients and the surgical workforce. We hypothesized that poor surgical glove quality may have contributed to the high incidence. Hence, we tested the integrity of six brands of sterile gloves. The assumption was the perforation rate in these gloves would be higher than the standard acceptable quality level (AQL).

From the 1,200 single gloves evaluated, 59 (4.9%) gloves had perforations. Brand 1 (13.5%) and Brand 5 (10%) had the highest rate of perforations, followed by Brand 3 (3.0%) Brand 6 (2.0%), Brand 2 (1.0%) and Brand 4, which had 0 perforations. Compared to the standard AQL 1.5 for surgical gloves at the time of the study, Brand 1 and Brand 5 had a significantly higher perforation rate (13.5%, CI=8.8%-18.2%, p=0.000) and (10.0%, CI=5.8%-14.2%, p=0.000), respectively.

Our study results showed unacceptably high rates of perforation for 2 glove brands. The implications of this are staggering for surgical staff. In Ethiopia, choice of surgical glove brand may be a determinant of surgical safety.

In view of our findings of a large proportion of glove perforations prior to use, we recommend, at minimum, that surgeons visually inspect gloves before and after donning. Relevant government institutions, contractors, importers, hospital administrators, and surgical teams must take collective responsibility for ensuring appropriate quality of gloves. Quality enforcement must be strengthened, and local production must be considered.

Context Specific Realities and Experiences of Nurses and Midwives in Basic Emergency Obstetric and Newborn Care Services in Two District Hospitals in Rwanda

Background
In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into the experiences of these healthcare workers in managing obstetric care emergencies are critical for improving quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. This is a qualitative part of a broader research about implementation of an mLearning and mHealth decision support tool (Safe Delivery Application), in basic emergency obstetric and newborn care services in Rwanda.

Methods
In this exploratory qualitative aspect of the research, the first author facilitated four focus group discussions with 26 nurses and midwives from two district hospitals in Rwanda. Each focus group discussion was made up of two parts. The first part focused on the participants’ reflections on the research results, while the second part explored their experiences of delivering obstetric care services in their respective district hospitals. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.

Results
Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants’ narratives of lived experiences of providing BEmONC services are presented under two broad themes: (1) self-reflections on their current practices and (2) contextual factors influencing the delivery of BEmONC services.

Conclusion
The insights of nurses and midwives regarding the management of birth related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on their management of PPH and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health particularly in low and middle income countries.

Unmet Surgical Need in Malawi

Introduction
Globally, and especially in sub-Saharan Africa, including Malawi, surgical conditions receive a low level of priority in national health systems. The burden of surgical diseases is not well documented and the reasons for which people still live with treatable conditions and disabilities or sometimes present late for care have also not been studied. There is also little information on surgical deaths from untreated conditions in both adults and children, including trauma, as well as potential barriers to obtaining surgical care.
Objectives
The aim of this thesis was therefore to describe the untreated surgical conditions, in both adults and children, the barriers to surgical health care, as well as to document information about deaths from surgical conditions in Malawi.
Methods
This thesis is based on four papers. All four involved data collected using the SOSAS tool, which is a questionnaire-based data collection tool for documenting household information in the communities. The tool had three sections, the first section capturing demographic data for the households; including number of occupants, ages, gender, location and type of household, and tribe. The next two sections were similar but involved interviewing two different people and asking about information relating to surgical conditions present for both adults and paediatric age groups, including injuries, associated disability from acquired or congenital disorders, transportation to health facility and location of death from different surgical conditions. The two household members interviewed, included the head of household and another random member within the household. Data collection was centrally organized by a project group, and performed by third year medical students from the University of Malawi, College of Medicine.
Data was collected as a national survey from the 28 districts in Malawi. The National Statistics Board helped us to identify the villages used in the study.
Results
We found that a third of the Malawian population were living with a surgical condition and were in need of a surgical consultation or treatment. These conditions were either congenital or the result of a traumatic or other non-traumatic condition. We also found that almost one fifth of the children with a surgical condition that could have been treated by surgery, instead remained with a disability that affected their daily lives.
In addition, we found that transportation poses a barrier to timely access to surgical health care. Transportation barriers included the lack of efficient public transportation, cost implications, and long travel distances to get to a health facility capable of offering care by either consultation or surgical procedures.
Other findings were that acute abdominal distention, body masses and trauma, contribute to surgical conditions that are highly associated with mortality in Malawian communities. We also noted that there are various reasons that lead to delays in obtaining formal health care, including initial consultations with traditional herbalists before going to the hospital.
Conclusion
Almost 6 million Malawian people, including an estimated 2 million children, are living with a condition that could be treated by either a surgical procedure or consultation. There are an estimated 1 million disabled children currently living with such surgically treatable conditions. The treatment of these conditions is hampered by transportation barriers. The transportation barriers have led to delays in obtaining timely surgical health care service, something that often leads to mortality. The common causes of these deaths are from injuries, but also other surgical emergencies. Most of these deaths occur outside a health facility environment.