Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania

Background
The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR).

Methods
An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis.

Results
Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry.

Conclusions
Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.

Perioperative serum albumin as a predictor of adverse outcomes in abdominal surgery: prospective cohort hospital based study in Northern Tanzania

Background: Albumin is an important protein that transports hormones, fatty acids, and exogenous drugs; it also maintains plasma oncotic pressure. Albumin is considered a negative active phase protein because it decreases during injuries and sepsis. In spite of other factors predicting surgical outcomes, the effect of pre and postoperative serum albumin to surgical complications can be assessed by calculating the percentage decrease in albumin (delta albumin). This study aimed to explore perioperative serum albumin as a predictor of adverse outcomes in major abdominal surgeries.

Methods: All eligible adult participants from Kilimanjaro Christian Medical Centre Surgical Department were enrolled in a convenient manner. Data were collected using a study questionnaire. Full Blood Count (FBP), serum albumin levels preoperatively and on postoperative day 1 were measured in accordance with Laboratory Standard Operating Procedures (SOP). Data was entered and analyzed using STATA version 14. Association and extent of decrease in albumin levels as a predictor of surgical site infection (SSI), delayed wound healing and death within 30 days of surgery was determined using ordinal logistic regression models. In determining the diagnostic accuracy, a Non-parametric Receiver Operating Curve (ROC) model was used. We adjusted for ASA classification, which had a negative confounding effect on the predictive power of the percent drop in albumin to adverse outcomes.

Results: Sixty one participants were studied; the mean age was 51.6 (SD16.3), the majorities were males 40 (65.6%) and post-operative adverse outcomes were experienced by 28 (45.9%) participants. In preoperative serum albumin values, 40 (67.8%) had lower than 3.4 g/l while 51 (91%) had postoperative albumin values lower than 3.4 g/l. Only 15 (27.3%) had high delta albumin with the median percentage value of 14.77%. Delta albumin was an independent significant factor associated with adverse outcome (OR: 6.68; 95% CI: 1.59, 28.09); with a good predictive power and area under ROC curve (AUC) of 0.72 (95% CI 0.55 0.89). The best cutoff value was 11.61% with a sensitivity of 76.92% and specificity of 51.72%.

Conclusion: Early perioperative decreases in serum albumin levels may be a good, simple and cost effective tool to predict adverse outcomes in major abdominal surgeries.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries

Background:
Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC.

Methods:
This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively.

Results:
A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. Conclusions: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.

Cancer incidence and treatment utilization patterns at a regional cancer center in Tanzania from 2008-2016: Initial report of 2,772 cases

Purpose: To describe cancer incidence and treatment utilization patterns at the regional cancer referral center for the Lake Zone of northwestern Tanzania from 2008 to 2016.

Methods: This descriptive, retrospective study reviewed all cancer cases recorded in the Bugando Cancer Registry (BCR), a clinical and pathology based registry at the only cancer referral hospital in the region. Primary tumor site, method of diagnosis, HIV status, and cancer treatment were reported. Using census data, the 2012 GLOBOCAN estimates for Tanzania were scaled to the Lake Zone and adjusted for 2016 population growth. These estimates were then compared to BCR cases using one-sample tests of proportion.

Results: A total of 2772 cases were reported from 2008-2016. Among these, the majority of cases (82.5 %, n = 2286) were diagnosed among adults. Most cases (85 %, n = 1923) were diagnosed by histology or cytology. Among adults, the most common cancers diagnosed were cervix (22.7 %, n=520), breast (12.6 %, n=288), and prostate (8.5 %, n=195). Among children, the most common cancers were non-Burkitt non-Hodgkin lymphoma (17.3 %, n=84), Burkitt lymphoma (16.5 %, n=80), and Wilms tumor (14.6 %, n=71). The 1116 BCR cases represent 12.2 % of the 9165 expected number of cancer cases for the Lake Zone (p < 0.001). 1494 cases (53.9 %) received some form of treatment - surgery, chemotherapy, radiation, or hormone therapy - while 1278 cases (46.1 %) had no treatment recorded. Conclusions: This comprehensive report of the BCR reveals cancer epidemiology and treatment utilization patterns typical of hospitals in low-resource settings. Despite being the only cancer center in the Lake Zone, BMC evaluates a small percentage of the expected number of cancer patients for the region. The BCR remains an important resource to guide clinical care and academic activities for the Lake Zone.

Oxygen availability in sub-Saharan African countries: a call for data to inform service delivery

Oxygen is central to the management of patients admitted to hospital with severe COVID-19. Furthermore, the availability of oxygen therapy is just as important for the management of other patients who are acutely ill. However, despite recognition from most health-care providers that oxygen is a fundamental component of a health-care system, it has not been a focus of health-care delivery in sub-Saharan African countries, as shown by the lack of data collected on oxygen availability.

Gynecological hysterectomy in Northern Tanzania: a cross- sectional study on the outcomes and correlation between clinical and histological diagnoses

Background
Hysterectomy is one of the most common gynaecological procedures performed worldwide. The magnitude of the complications related to hysterectomy and their risk factors are bound to differ based on locations, availability of resources and level of surgical training. Documented complications rates and their correlates are reported from high income countries while data from low- and middle-income countries including Tanzania is scare.
Methods
This was a hospital based cross-sectional study conducted at a tertiary facility in northern Tanzania where 178 women who underwent elective gynecological hysterectomies in the department of obstetrics and gynecology within the study period were enrolled. Logistic regression was performed to determine the association between risk factors and occurrence of surgical complication where p-value of  2 h) (OR 5.02; 95% CI 2.18–11.5). Both uterine fibroid and adenomyosis had good correlation of clinical and histological diagnosis (p-value < 0.001).
Conclusion
Bleeding and blood transfusion were the most common complications observed in this study. Obesity, previous abdominal operation and prolonged duration of operation were the most significant risk factors for the complications. Local tailored interventions to reduce surgical complications of hysterectomy are thus pivotal. Clinicians in this locality should have resources at their disposal to enhance definitive diagnosis attainment before surgical interventions.

Aetiologies and Outcomes of Patients With Abdominal Pain Presenting to an Emergency Department of a Tertiary Hospital in Tanzania: A Prospective Cohort Study

Background: Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania.

Methods: This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality.

Results: Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35-60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p < 0.0001), receipt of IV fluids (RR) 3.2 (p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001). Conclusion: Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.

Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.

m-Health for Burn Injury Consultations in a Low-Resource Setting: An Acceptability Study Among Health Care Providers

Introduction:The rapid adoption of smartphones, especially in low- and middle-income countries, has opened up novel ways to deliver health care, including diagnosis and management of burns. This study was conducted to measure acceptability and to identify factors that influence health care provider’s attitudes toward m-health technology for emergency care of burn patients.

Methods:An extended version of the technology acceptance model (TAM) was used to assess the acceptability toward using m-health for burns. A questionnaire was distributed to health professionals at four hospitals in Dar Es Salaam, Tanzania. The questionnaire was based on several validated instruments and has previously been adopted for the sub-Saharan context. It measured constructs, including acceptability, usefulness, ease of use, social influences, and voluntariness. Univariate analysis was used to test our proposed hypotheses, and structural equation modeling was used to test the extended version of TAM.

Results:In our proposed test-model based on TAM, we found a significant relationship between compatibility—usefulness and usefulness—attitudes. The univariate analysis further revealed some differences between subgroups. Almost all health professionals in our sample already use smartphones for work purposes and were positive about using smartphones for burn consultations. Despite participants perceiving the application to be easy to use, they suggested that training and ongoing support should be available. Barriers mentioned include access to wireless internet and access to hospital-provided smartphones.

Nonoperative Treatment of Traumatic Spinal Injuries in Tanzania: Who Is Not Undergoing Surgery and Why?

Study design: Retrospective, cohort study of a prospectively collected database.

Objectives: In a cohort of patients with traumatic spine injury (TSI) in Tanzania who did not undergo surgery, we sought to: (1) describe this nonoperative population, (2) compare outcomes to operative patients, and (3) determine predictors of nonoperative treatment.

Setting: Tertiary referral hospital.

Methods: All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, fracture morphology, neurologic exam, indication for surgery, length of hospitalization, and mortality. Regression analyses were used to report outcomes and predictors of nonoperative treatment.

Results: 270 patients met inclusion criteria, of which 145 were managed nonoperatively. Demographics between groups were similar. The nonoperative group was young (mean = 35.5 years) and primarily male (n = 125, 86%). Nonoperative patients had 7.39 times the odds of death (p = 0.003). Patients with AO type A0/1/2/3 fractures (p < 0.001), ASIA E exams (p = 0.016), cervical spine injuries (p = 0.005), and central cord syndrome (p = 0.016) were more commonly managed nonoperatively. One hundred and twenty-four patients (86%) had indications for but did not undergo surgery. After multivariate analysis, the only predictor of nonoperative management was sustaining a cervical injury (p < 0.001).

Conclusions: Eighty-six percent of nonoperative TSI patients had an indication for surgery. Nonoperative management was associated with an increased risk of mortality. Cervical injury was the single independent risk factor for not undergoing surgery. The principle reason for nonoperative management was cost of implants. While a causal relationship between nonoperative management and inferior outcomes cannot be made, efforts should be made to provide surgery when indicated, regardless of a patient's ability to pay.