Patient-Reported Outcome Measures for Acetabular Fractures Treated Operatively without a C-Arm in Ethiopia

Background:
There is little evidence describing the open treatment of displaced acetabular fractures in low-resource environments. We endeavored to determine the results of the operative management of acetabular fractures without intraoperative C-arm use in a developing nation, through the assessment of patient-reported outcome measures.

Methods:
This was a prospective, single-surgeon, consecutive case series conducted in a tertiary referral hospital in Ethiopia, a high-population, low-income country. The primary author performed fixation without the use of a C-arm in 108 patients from among a total of 202 patients presenting with acetabular fracture. The modified Harris hip score (mHHS) and Short-Form Health Survey (SF)-36 at a minimum of 2 years postoperatively were used to assess the outcome.

Results:
Of the 108 patients potentially available for analysis, 92 (85%) were available for 2-year follow-up (mean age of 35 years; range, 15 to 70 years). The mean duration from injury to surgery was 16 days (range, 1 to 204 days). Seventy-three (78.5%; n = 93) of the patients had associated fracture patterns. The most common fractures were associated both-column type (22%) and transverse-plus-posterior-wall type (22%). The mean mHHS was 91; 88% of the patients had a score of ≥80, and 12% had a score of ≤79. SF-36 scores were in alignment with the mHHS. The majority (approximately 90%) of our cohort returned to work. We did not find a significant difference in the mean mHHS between patients with or without anatomic reduction (p = 0.31). However, 2-year radiographic outcomes were strongly associated with the mean mHHS (p < 0.001). Predictors of a lower mHHS included older age, cartilage damage, and lack of secondary congruence. Conclusions: Good functional outcomes were achieved at 2 years among patients with acetabular fractures surgically treated without the use of a C-arm in a limited-resource setting. Surgical congruence of the femoral head under the acetabular roof, rather than the absolute residual gap, seems essential in determining clinical outcomes. This information can help in planning increased access to care for individuals who experience traumatic injuries in low- and middle-income countries.

Implementing surgical mentorship in a resource-constrained context: a mixed methods assessment of the experiences of mentees, mentors, and leaders, and lessons learned

Background
A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource–constrained settings.

Methods
We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes.

Results
All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention.

Conclusion
We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention’s success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

Virtual reality technology in linked orthopaedic training in Ethiopia

Introduction
We describe the feasibility of delivering a live orthopaedic surgical teaching session with virtual reality (VR) technology simultaneously for trainee surgeons in Ethiopia and the UK.

Methods
Forty-three delegates from the Severn Deanery in the UK (n=30) and Bahir Dar in Ethiopia (n=13) attended a live training session in February 2021. During the session, participants watched a surgical operation (recorded earlier that week with a 360° VR camera) alongside live commentary. A qualitative questionnaire was distributed to gauge feasibility, connectivity and educational value of the session as well as its VR component.

Results
The majority of delegates from both the UK and Ethiopia felt that the use of VR technology to aid surgical training is feasible, that it is useful for learning surgical approaches, that it aids surgical performance and that it is superior to conventional resources. Bahir Dar residents strongly agreed that VR simulation videos would allow trainees to supplement reduced learning opportunities as a result of the COVID-19 pandemic and help to counteract their reduced operating experience. For Bahir Dar trainees, a lack of a stable internet connection for large VR files was the predominant issue.

Conclusions
This study demonstrates that there are infrastructure challenges in low and middle income countries (LMICs) in terms of the reliable delivery of VR teaching in orthopaedics at the current time. Despite this, our findings better inform the potential role of VR technology in surgical education, and shed light on the possibility for it to feed into and enrich surgical training in both LMICs and high income countries.

Quality of emergency obstetric and newborn care services in Wolaita Zone, Southern Ethiopia

Background
Globally, nearly 295,000 women die every year during and following pregnancy and childbirth. Emergency obstetric and newborn care (EmONC) can avert 75% of maternal mortality if all mothers get quality healthcare. Improving maternal health needs identification and addressing of barriers that limit access to quality maternal health services. Hence, this study aimed to assess the quality of EmONC service and its predictors in Wolaita Zone, southern Ethiopia.

Methodology
A facility-based cross-sectional study was conducted in 14 health facilities. A facility audit was conducted on 14 health facilities, and 423 women were randomly selected to participate in observation of care and exit interview. The Open Data Kit (ODK) platform and Stata version 17 were used for data entry and analysis, respectively. Frequencies and summary statistics were used to describe the study population. Simple and multiple linear regressions were done to identify candidate and predictor variables of service quality. Coefficients with 95% confidence intervals were used to declare the significance and strength of association. Input, process, and output quality indices were created by calculating the means of standard items available or actions performed by each category and were used to describe the quality of EmONC.

Result
The mean input, process, and output EmONC services qualities were 74.2, 69.4, and 79.6%, respectively. Of the study participants, 59.2% received below 75% of the standard clinical actions (observed quality) of EmONC services. Women’s educational status (B = 5.35, 95% C.I: 0.56, 10.14), and (B = 8.38, 95% C.I: 2.92, 13.85), age (B = 3.86, 95% C.I: 0.39, 7.33), duration of stay at the facility (B = 3.58, 95% C.I: 2.66, 4.9), number of patients in the delivery room (B = − 4.14, 95% C.I: − 6.14, − 2.13), and care provider’s experience (B = 1.26, 95% C.I: 0.83, 1.69) were independent predictors of observed service quality.

Conclusion
The EmONC services quality was suboptimal in Wolaita Zone. Every three-in-five women received less than three-fourths of the standard clinical actions. The health system, care providers, and other stakeholders should emphasize improving the quality of care by availing medical infrastructure, adhering to standard procedures, enhancing human resources for health, and providing standard care regardless of women’s characteristics.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers’ perspective

Background
Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce.

Methods
This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate).

Results
The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer.

Conclusions
The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Patterns of injuries among Children visiting Gondar town public health institutes, Northwest Ethiopia, 2019

Background: Injuries have been recognized as the leading cause of death in children for nearly 40 years. However, most epidemiological studies of injuries have not been community-based and are limited either to a single type of injury, such as head injuries or burnsor to a specific cause of injury, such as consumer products.

Objective: To determine patterns of injuries among children visiting Gondar town public health institutes, Northwest Ethiopia,2019.

Methods: An institutional-based prospective cross-sectional study was conductedamong children visiting Gondar town public health institutes of Amhara region, Northwest Ethiopia from June 25 to September 25, 2019. A total of 385 participants were included in the study. Data were entered into Epi-info version 7.2.1 and exported to SPSS version 21.0 for analysis and descriptive statistics were presented in text, tables, charts, and graphs.

Result: The majority of the pediatric trauma cases were seen in males 61.8%, (n = 238) and females comprised only 38.2% (n = 147). Stone or stick injury (29.1%) was the most common mode of trauma followed by road traffic injuries (21.0%), falls (19.0%), and burns (14.0%). The majority of injuries happened during playing (53%) and around the home (37.9%). In this study the three top most frequent sites of injuries were: lower extremity injury 167 (43.4%), upper extremity127 (33.0%), and head injury 50 (13.0%).

Conclusion and recommendation: The high rate of pediatric trauma from sticks or stones, roadways, and falls highlights the need for increased supervision and identification of specific dangers when playing. In our scenario, a comprehensive trauma registry appears to be critical for developing policies to lessen the burden of pediatric trauma. Further research with large sample size and associated factors for pediatric injuries is recommended.

Compliance with the World Health Organization’s surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia

Background
Ministry of Health (MOH) of Ethiopia adopted World Health Organization’s evidence-proven surgical safety checklist (SSC) to reduce the occurrence of surgical complications, i.e., death, disability and prolong hospitalization. MOH commissioned this evaluation to learn about SSC completeness and compliance, and its effect on magnitude of surgical complications.

Methods
Health institution-based cross-sectional study with retrospective surgical chart audit was used to evaluate SSC utilization in 172 public and private health facilities in Ethiopia, December 2020–May 2021. A total of 1720 major emergency and elective surgeries in 172 (140 public and 32 private) facilities were recruited for chart review by an experienced team of surgical clinicians. A pre-tested tool was used to abstract data from patient charts and national database. Analyzed descriptive, univariable and bivariable data using Stata version-15 statistical software.

Results
In 172 public and private health facilities across Ethiopia, 1603 of 1720 (93.2%) patient charts were audited; representations of public and private facilities were 81.4% (n = 140) and 18.6% (n = 32), respectively. Of surgeries that utilized SSC (67.6%, 1083 of 1603), the proportion of SSC that were filled completely and correctly were 60.8% (659 of 1083). Surgeries compliant to SSC guide achieved a statistically significant reduction in perioperative mortality (P = 0.002) and anesthesia adverse events (P = 0.005), but not in Surgical Site Infection (P = 0.086). Non-compliant surgeries neither utilized SSC nor completed the SSC correctly, 58.9% (944 of 1603).

Conclusions
Surgeries that adhered to the SSC achieved a statistically significant reduction in perioperative complications, including mortality. Disappointingly, a significant number of surgeries (58.9%) failed to adhere to SSC, a missed opportunity for reducing complications.

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.

Phenotypic Bacterial Isolates, Antimicrobial Susceptibility Pattern and Associated Factors among Septicemia Suspected Patients at a hospital, in Northwest Ethiopia. Prospective cross- sectional study

Background
Septicemia is a life-threatening infection when pathogenic bacteria infiltrate the bloodstream, leading morbidity and mortality in Ethiopian hospital patients. Multidrug resistance is a therapeutic challenge among this patient and has a paucity of data in the hospitals. Therefore, this study aimed to assess the bacterial isolates, antimicrobial susceptibility pattern, and associated factors among septicemia suspected patients.

Methods
Prospective cross-sectional study was conducted among 214 septicemia suspected patients from February to June 2021 a hospital in northwest, Ethiopia. Blood samples were collected aseptically and processed to identify bacterial isolates by using different standard microbiological procedures. Antimicrobial susceptibility pattern was performed using the modified Kirby Bauer disc diffusion on Mueller Hinton agar. Epi-data V4.2 was used to enter data and SPSS V25 for analysis. The variables were assessed using a bivariate logistic regression model with a 95% confidence interval, and declared statistically significant; P-value was < 0.05.

Results
The overall bacterial isolates was found 45/214 (21%) in this study. Gram-negative and positive bacteria were 25/45(55.6%), 20/45(44.4%) respectively. The most common bacterial isolates were Staphylococcus aureus12/45 (26.7%), Klebsiella pneumonia8/45(17.8%), Escherichia coli 6/45 (13.3%). Gram-negative bacteria showed susceptible to amikacin (88%), meropenem, imipenem (76%), but resistance to (92%) ampicillin, (85.7%) amoxicillin-clavulanic acid. S.aureus (91.7%) resistance to Penicillin, (58.3%) cefoxitin and (75%) susceptible to ciprofloxacillin. S.pyogenes and S.agalactia were (100%) susceptible to Vancomacin. Multidrug resistance was found in 27/45(60%) of the bacterial isolates. The main predictors related to patients suspected of septicemia were prolonged hospitalization (AOR = 2.29, 95% CI: 1.18, 7.22), fever (AOR = 0.39, 95%CI: 0.18, 0.85) and length of hospital stay (AOR = 0.13, 95%CI: 0.02, 0.82).

Conclusions
Bacterial isolates among septicemia suspected patients were high. The majority of the bacterial isolates were multidrug-resistant. To prevent antimicrobial resistance, specific antibiotic utilization strategy should be applied.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.