Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review
Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings
A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Summary
Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Evaluation of capacity to deliver emergency obstetrics and newborn care updated midwifery and reproductive health training curricula in Kenya: Before and after study

Introduction
Provision of emergency obstetric and newborn care (EmONC) by skilled health personnel reduces maternal and newborn mortality. Pre-service diploma midwifery and clinical medicine (reproductive health) curricula in Kenya were reviewed and updated integrating the competency based EmONC curriculum. A two-part (virtual for theoretical component and face-to-face for the skills-based component) capacity building workshop for national midwifery/clinical medicine trainers of trainers to improve their capacity to implement the updated curricula and cascade it to colleagues nationwide was conducted.

Purpose
This paper measured change in confidence of pre-service midwifery/clinical medicine educators to deliver the updated competency-based curricula in Kenya.

Methods
A before-after study among 51 midwifery/clinical medicine educators from 35 training colleges who participated in upskilling workshops as trainers-of-trainers for the updated curricula between September-November 2020. Assessment included self-reported confidence using a 3-point Likert scale (not confident, somewhat confident or extremely confident) in facilitating online teaching (as COVID-19 pandemic containment measure), EmONC skills teaching/demonstration; scenario/simulation teaching, small group discussions, peer review and giving effective feedback. Analysis involved test of proportions with p-values < 0.05 statistically significant. Results Educators’ confidence significantly improved in facilitating virtual teaching (46% to 70%, p = 0.0082). On the competency-based training, the confidence among educators significantly increased in facilitating EmONC skills teaching/demonstration (44% to 96%), facilitating scenario/simulation teaching (46% to 92%), facilitating small group discussions (46% to 94%), giving effective feedback (46% to 92%), and peer review and feedback (47% to 77%), p < 0.05). Conclusion The blended training improved the confidence of pre-service educators to deliver the updated midwifery/clinical medicine curricula.

Development of the anaesthesia workforce and organisation of the speciality in Uganda: a mixed-methods case study

Background: The development of modern anaesthesia practice in many low-income countries has lagged behind that of highincome countries despite early reports. Detailed descriptions of ‘surgery under anaesthesia’ in Uganda are available through Robert W. Felkin’s elaborate accounts of caesarean sections done in the Bunyoro-Kitara Kingdom. However, the earliest documented ‘modern’ surgical and anaesthesia procedures were performed by Sir Albert Cook and his brother Dr Jack Cook in 1897 at Mengo Hospital. Since then, anaesthesia has developed into an independent speciality with workforce development, professional bodies and a recognised practice. This study aimed to describe the development of the anaesthesia workforce and speciality since independence while sharing our experiences to benefit those countries on a similar journey.

Methods: We employed a mixed-methods approach, including surveys among anaesthesia providers, as well as key informant interviews and a workforce database review. Whenever possible, information was corroborated with written literature.

Results: There are three levels of training of anaesthesia providers in Uganda, including a Master of Medicine in anaesthesia for specialist physician providers, a Bachelor of Science in anaesthesia and a Higher Diploma in anaesthesia for non-physician providers. There are two Master of Medicine programmes, two Bachelor of Science in anaesthesia programmes and seven Higher Diploma programmes. The existing workforce consists of 68 specialists and more than 600 non-physician providers. The anaesthesia providers are organised under professional associations, namely the Association of Anesthesiologists of Uganda and the Uganda Anaesthetic Officers Association. International and regional collaborations have been critical in the development of anaesthesia in Uganda.

Conclusion: Uganda still has a low density of anaesthesia providers both in number and distribution but has established critical steps to substantially increase the workforce. These steps include three levels of training with numerous training programmes, professional bodies and partnerships. We present our experiences with different strategies, highlighting those that have failed, and suggest further recommendations on developing anaesthesia in Uganda.

The lived experience of people with upper limb absence living in Uganda: A qualitative study

Background: The impact of upper limb absence on people’s lived experiences is understudied, particularly in African countries, with implications for policy and service design.
Objectives: The objective of this study was to explore the lived experiences of people with upper limb absence (PWULA) living in Uganda.
Method: Informed by preliminary work, we designed a qualitative study employing semistructured interviews to understand the experience of living with upper limb absence in Uganda. Seventeen adults with upper limb absence were individually interviewed and their interviews were analysed utilising thematic analysis.
Results: Seven themes illustrating the impact on the individual’s life after amputation were identified and categorised into (1) living and adapting to life, (2) productivity and participation and (3) living within the wider environment. This study presents three main findings: (1) PWULA need psychological and occupational support services which are not available in Uganda, (2) PWULA want to work, but face multiple barriers to employment and has limited support, combined with the complex parenting and caring responsibilities, (3) the local Ugandan culture and social structures affect the everyday life of PWULA, both in positive and negative ways.
Conclusion: This study provides information on the lived experiences of PWULA in Uganda which are lacking in the literature. People with upper limb absence face ableism and hardship underpinned by a lack of formal support structures and policies, which may in turn exacerbate the impact of upper limb absence on multiple facets of lif

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

Background
There is an increasing call for a broader approach to women’s surgical care in low- and middle-income countries, beyond access to caesarean section. While obstetric outcomes in Africa are well described, outcomes following non-obstetric surgical care for women in Africa are relatively unknown. Methods We did a secondary analysis of the African Surgical Outcomes Study (ASOS) focusing on severe postoperative complications (defined as death and severe complications) in females following non-obstetric, non-gynaecological surgical procedures. ASOS was a seven-day, African multi-centre prospective observational cohort study of adult (≥18 years) patients undergoing surgery in 25 African countries. These African outcomes were compared to international outcomes from the International Surgical Outcomes Study (ISOS) in a riskadjusted logistic regression analysis. Findings There were 1498 African participants and 18449 international participants who met the inclusion criteria. The African cohort were younger than the international cohort (47 (17) years versus 57 (17); p= <0·0001) and had a lower preoperative risk profile. Severe complications occurred in 41 (2·8%) of 1471 patients of the African cohort, and 431 (2·3%) of 18449 patients in the ISOS cohort, with in-hospital mortality following severe complications of 20/41 (48·8%) in ASOS and 78/431 (18·1%) in ISOS. The adjusted odds ratio for a woman in Africa developing a severe postoperative complication following elective non-obstetric, non-gynaecological surgery compared to the international incidence was 2·114 (95% CI 1·468 – 3·042, p<0·0001). Interpretation: Women living in Africa have double the odds of severe postoperative complications following elective non-obstetric, non-gynaecological surgery compared to the international incidence.

Exploring the lived experiences of parents caring for infants with gastroschisis in Rwanda: The untold story

Pediatric surgery is a crucial pillar of health equity but is often not prioritized in the global health agenda, especially in low-and middle-income countries. Gastroschisis (GS) is a type of structural congenital anomaly that can be treated through surgical interventions. In Rwanda, neonatal surgical care is only available in one hospital. The experience of parents of children born with gastroschisis has not been previously studied in Rwanda. The objective of this study was to explore the lived experiences of parents of children diagnosed with GS in Rwanda. A qualitative study using a semi-structured interview guide was conducted. Parents who had children with gastroschisis and were discharged alive from the hospital in Rwanda were interviewed by trained data collectors, from May to July 2021. Data were transcribed, translated, and then coded using a structured code-book. Thematic analysis was conducted with the use of Dedoose software. Sixteen parents participated in the study. Five themes emerged from the data. They were: “GS diagnosis had a significant emotional impact on the parents”, “Parents were content with the life-saving medical care provided for their children despite some dissatisfaction due to the delayed initiation of care and shortage of medications”, “GS care was accompanied by financial challenges”, “support systems were important coping mechanisms” and “the impact of GS care extended into the post-discharge period”. Having a newborn with GS was an emotional journey. The lack of pre-knowledge about the condition created a shock to the parents. Parents found support from their faith and other parents with similar experiences. The experiences with the care received were mostly positive. The overall financial burden incurred from the medical treatment and indirect costs was high and extended beyond the hospital stay. Strengthening prenatal and hospital services, providing peer, spiritual and financial support could enhance the parents’ experience.

Coaching for impact: successful implementation of a multi-national, multi-institutional synchronous research course in Ethiopia

Purpose
Under the American College of Surgeons’ Operation Giving Back, several US institutions collaborated with a teaching and regional referral hospital in Ethiopia to develop a surgical research curriculum.

Methods
A virtual, interactive, introductory research course which utilized a web-based classroom platform and live educational sessions via an online teleconferencing application was implemented. Surgical and public health faculty from the US and Ethiopia taught webinars and led breakout coaching sessions to facilitate participants’ project development. Both a pre-course needs assessment survey and a post-course participation survey were used to examine the impact of the course.

Results
Twenty participants were invited to participate in the course. Despite the majority of participants having connection issues (88%), 11 participants completed the course with an 83% average attendance rate. Ten participants successfully developed structured research proposals based on their local clinical needs.

Conclusion
This novel multi-institutional and multi-national research course design was successfully implemented and could serve as a template for greater development of research capacity building in the low- and middle-income country (LMIC) setting.

Exploring health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion in Central Uganda

Introduction
Women living in low- and middle-income countries still have limited access to quality second trimester post abortion care. We aim to explore health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion.

Methods
This qualitative study used the phenomenology approach. We conducted 48 in-depth interviews for doctors and midwives at 14 public health facilities in central Uganda using a flexible interview guide. We used inductive content analysis and made code frequencies based on health care provider cadre, and health facility level and then abstracted themes from categories.

Results
Well trained midwives were perceived as competent to manage second trimester post abortion care stable patients, however doctor’s supervision in case of complications was considered important. Sometimes, midwives were seen as offering better care than doctors given their stronger presence in the facilities. Misoprostol received unanimous support and viewed as: safe, effective, cheap, convenient, readily available, maintained patient privacy, and saved resources. Challenges faced included: side effects, prolonged hospital stay, treatment failure, inclination to surgical evacuation, heavy work load, inadequate space, lack of medical commodities, frequent staff rotations which affects the quality of patient care. To address these challenges, respondents coped by: giving patients psychological support, analgesics, close patient monitoring, staff mentorship, commitment to work, team work and patient involvement in care.

Conclusion
Misoprostol is perceived as an ideal uterine evacuation method for second trimester post abortion care of uncomplicated patients and trained midwives are considered competent managing these patients in a health facility setting with a back-up of a doctor. Health care providers require institutional and policy environment support for improved service delivery.

The impact of the Fundamental Critical Course on knowledge acquisition in Rwanda

Background. Emerging critical care systems have gained little attention in low- and middle-income countries. In sub-Saharan Africa, only 4% of the healthcare workforce is trained in critical care, and mortality rates are unacceptably high in this patient population.
Aim. We sought to retrospectively describe the knowledge acquisition and confidence improvement of practitioners who attend the Fundamental Critical Care Support (FCCS) course in Rwanda.
Methods. We conducted a retrospective study in which we assessed survey data and multiple-choice question data that were collected before and after course delivery. The purpose of these assessments at the time of delivery was to evaluate participants’ perception and acquisition of critical care knowledge.
Results. Thirty-six interprofessional clinicians completed the training. Performance on the multiple-choice questions improved overall after the course (mean score pre-course of 56.5% to mean score post-course of 65.8%,p-value <0.001) and improved in all content areas with the exception of diagnosis and management of acute coronary syndrome and acute respiratory failure/mechanical ventilation. Both physicians and nurses improved their scores significantly (68.9% to 75.6%,p-value = 0.031 and 52.0% to 63.5%,p-value <0.001, respectively). Self-reported
confidence in level of knowledge also increased in all areas. Survey respondents indicated on open-answer questions that they would like the course offerings at least annually, and that further dissemination of the course in Rwanda was warranted.
Conclusion. Deploying the established FCCS course improved Rwandan healthcare provider knowledge and confidence across most critical care content areas. Therefore, this course represents a good first step in bridging the gaps noted in emerging critical care systems.

User Perceptions and Use of an Enhanced Electronic Health Record in Rwanda With and Without Clinical Alerts: Cross-sectional Survey

Background:
Electronic health records (EHRs) have been implemented in many low-resource settings but lack strong evidence for usability, use, user confidence, scalability, and sustainability.

Objective:
This study aimed to evaluate staff use and perceptions of an EHR widely used for HIV care in >300 health facilities in Rwanda, providing evidence on factors influencing current performance, scalability, and sustainability.

Methods:
A randomized, cross-sectional, structured interview survey of health center staff was designed to assess functionality, use, and attitudes toward the EHR and clinical alerts. This study used the associated randomized clinical trial study sample (56/112, 50% sites received an enhanced EHR), pulling 27 (50%) sites from each group. Free-text comments were analyzed thematically using inductive coding.

Results:
Of the 100 participants, 90 (90% response rate) were interviewed at 54 health centers: 44 (49%) participants were clinical and 46 (51%) were technical. The EHR top uses were to access client data easily or quickly (62/90, 69%), update patient records (56/89, 63%), create new patient records (49/88, 56%), generate various reports (38/85, 45%), and review previous records (43/89, 48%). In addition, >90% (81/90) of respondents agreed that the EHR made it easier to make informed decisions, was worth using, and has improved patient information quality. Regarding availability, (66/88) 75% said they could always or almost always count on the EHR being available, whereas (6/88) 7% said never/almost never. In intervention sites, staff were significantly more likely to update existing records (P=.04), generate summaries before (P<.001) or during visits (P=.01), and agree that “the EHR provides useful alerts, and reminders” (P<.01).

Conclusions:
Most users perceived the EHR as well accepted, appropriate, and effective for use in low-resource settings despite infrastructure limitation in 25% (22/88) of the sites. The implementation of EHR enhancements can improve the perceived usefulness and use of key functions. Successful scale-up and use of EHRs in small health facilities could improve clinical documentation, care, reporting, and disease surveillance in low- and middle-income countries.