Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward

This chapter is based on persons with physical disabilities in Africa, their challenges, and how it affects their health-seeking behaviors. We noticed that physical challenge has a substantial long-term adverse effect on one’s ability to carry out normal day-to-day activities. Both the causes and the consequences of physical disability vary throughout the world, especially in Africa. Environmental, technical, and attitudinal barriers and consequent social exclusion reduce the opportunities for physically challenged persons to contribute productively to the household and the community and further increase the risk of falling into poverty and poor healthcare services. The inability of the physically challenged persons to perceive the lack of points of interest of government has intensified to make significant recommendations and possible solutions. This is appalling because the rate to which a community provides and funds restoration is a way of grading how much interest it has, and importance it connects to the quality of life of its citizens. We advocate and recommend swift actions and disability inclusiveness to accommodate persons with physical disabilities in Africa for them to have a good perception of life.

Directly observed and reported respectful maternity care received during childbirth in public health facilities, Ibadan Metropolis, Nigeria

Respectful maternity care (RMC) is believed to improve women’s childbirth experience and increase health facility delivery. Unfortunately, few women in low- and middle-income countries experience RMC. Patient surveys and independent observations have been used to evaluate RMC, though seldom together. In this study, we assessed RMC received by women using two methodologies and evaluated the associated factors of RMC received. This was a cross-sectional study conducted in nine public health facilities in Ibadan, a large metropolis in Nigeria. We selected 269 pregnant women by cluster sampling. External clinical observers observed them during childbirth using the 29-item Maternal and Child Health Integrated Program RMC observational checklist. The same women were interviewed postpartum using the 15-item RMC scale for self-reported RMC. We analysed total RMC scores and RMC sub-category scores for each tool. All scores were converted to a percentage of the maximum possible to facilitate comparison. Correlation and agreement between the observed and reported RMC scores were determined using Pearson’s correlation and Bland-Altman analysis respectively. Multiple linear regression was used to identify factors associated with observed RMC. No woman received 100% of the observed RMC items. Self-reported RMC scores were much higher than those observed. The two measures were weakly positively correlated (rho = 0.164, 95%CI: 0.045–0.278, p = 0.007), but had poor agreement. The lowest scoring sub-categories of observed RMC were information and consent (14.0%), then privacy (28.0%). Twenty-eight percent of women (95%CI: 23.0% -33.0%) were observed to be hit during labour and only 8.2% (95%CI: 4.0%-18.0%) received pain relief. Equitable care was the highest sub-category for both observed and reported RMC. Being employed and having completed post-secondary education were significantly associated with higher observed RMC scores. There were also significant facility differences in observed RMC. In conclusion, the women reported higher levels of RMC than were observed indicating that these two methodologies to evaluate RMC give very different results. More consensus and standardisation are required in determining the cut-offs to quantify the proportion of women receiving RMC. The low levels of RMC observed in the study require attention, and it is important to ensure that women are treated equitably, irrespective of personal characteristics or facility context.

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

Background
Improving women’s health is a critical component of the sustainable development goals. Although obstetric outcomes in Africa have received significant focus, non-obstetric surgical outcomes for women in Africa remain under-examined.

Methods
We did a secondary analysis of the African Surgical Outcomes Study (ASOS) and International Surgical Outcomes Study (ISOS), two 7-day prospective observational cohort studies of outcomes after adult inpatient surgery. This sub-study focuses specifically on the analysis of the female, elective, non-obstetric, non-gynaecological surgical data collected during these two large multicentre studies. The African data from both cohorts are compared with international (non-African) outcomes in a risk-adjusted logistic regression analysis using a generalised linear mixed-effects model. The primary outcome was severe postoperative complications including in-hospital mortality in Africa compared with non-African outcomes.

Results
A total of 1698 African participants and 18 449 international participants met the inclusion criteria. The African cohort were younger than the international cohort with a lower preoperative risk profile. Severe complications occurred in 48 (2.9%) of 1671, and 431 (2.3%) of 18 449 patients in the African and international cohorts, respectively, with in-hospital mortality after severe complications of 23/48 (47.9%) in Africa and 78/431 (18.1%) internationally. Women in Africa had an adjusted odds ratio of 2.06 (95% confidence interval, 1.17–3.62; P=0.012) of developing a severe postoperative complication after elective non-obstetric, non-gynaecological surgery, compared with the international cohort.

Conclusions
Women in Africa have double the risk adjusted odds of severe postoperative complications (including in-hospital mortality) after elective non-obstetric, non-gynaecological surgery compared with the international incidence.

Safety culture and adverse event reporting in Ghanaian healthcare facilities: Implications for patient safety

Introduction
Recognizing the values and norms significant to healthcare organizations (Safety Culture) are the prerequisites for safety and quality care. Understanding the safety culture is essential for improving undesirable workforce attitudes and behaviours such as lack of adverse event reporting. The study assessed the frequency of adverse event reporting, the patient safety culture determinants of the adverse event reporting, and the implications for Ghanaian healthcare facilities.

Methods
The study employed a multi-centre cross-sectional survey on 1651 health professionals in 13 healthcare facilities in Ghana using the Survey on Patient Safety (SOPS) Culture, Hospital Survey questionnaire. Analyses included descriptive, Spearman Rho correlation, one-way ANOVA, and a Binary logistic regression model.

Results
The majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities. Teamwork (Mean: 4.18, SD: 0.566) and response to errors (Mean: 3.40, SD: 0.742) were the satisfactory patient safety culture. The patient safety culture dimensions were statistically significant (χ2 (9, N = 1642) = 69.28, p < .001) in distinguishing between participants who frequently reported adverse events and otherwise. Conclusion Promoting an effective patient safety culture is the ultimate way to overcome the challenges of adverse event reporting, and this can effectively be dealt with by developing policies to regulate the incidence and reporting of adverse events. The quality of healthcare and patient safety can also be enhanced when healthcare managers dedicate adequate support and resources to ensure teamwork, effective communication, and blame-free culture.

Assessment of Knowledge, Skills, and Preparedness of General-Duty Police on Prehospital Care of Road Traffic Accident Victims in Abuja, Nigeria

Objectives:
Prompt prehospital care (PHC) is essential for improving outcomes of road traffic accident victims. Previous studies in Nigeria show that little or no PHC is delivered to trauma victims by first responders. This study was conducted to assess police officers’ experience with FA/BLS, to identify gaps in their FA/BLS knowledge and skills, and assess police stations’ FA/BLS equipment capacity for PHC of road traffic accident victims.

Methods:
This cross-sectional study was conducted among 428 GD police in Abuja between November and December 2018. Respondents were selected using stratified random sampling with proportional allocation method. Data were collected using self-administered electronic semi-structured questionnaires. Data analysis was done using STATA v 14.0 (StataCorp, College Station, TX). Chi-square and multivariate logistic regression were used to assess associations.

Results:
We analyzed data from 419 respondents. Almost all (90.2%) of the police were aware of FA/BLS. The proportion of police with poor, fair, and good knowledge and skills on FA/BLS were 15.3%, 79.0%, and 5.7%, respectively. Tertiary (OR = 3.35, 95% CI: 1.01-11.11, P = 0.048) and postgraduate (OR = 6.89, 95% CI: 1.63-29.19, P = 0.009) levels of education had statistically significant association with good knowledge and skills.

Conclusion:
This highlights the need to implement an educational intervention to increase FA/BLS competencies within the first responder population

State of African neurosurgical education: a protocol for an analysis of publicly available curricula

Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.

Rural–urban disparities in caesarean deliveries in sub-Saharan Africa: a multivariate non-linear decomposition modelling of Demographic and Health Survey data

Introduction
Globally, the rate of caesarean deliveries increased from approximately 16.0 million in 2000 to 29.7 million in 2015. In this study, we decomposed the rural–urban disparities in caesarean deliveries in sub-Saharan Africa.

Methods
Data for the study were extracted from the most recent Demographic and Health Surveys of twenty-eight countries in sub-Saharan Africa. We included 160,502 women who had delivered in health facilities within the five years preceding the survey. A multivariate non-linear decomposition model was employed to decompose the rural–urban disparities in caesarean deliveries. The results were presented using coefficients and percentages.

Results
The pooled prevalence of caesarean deliveries in the 28 countries considered in the study was 6.04% (95% CI = 5.21–6.88). Caesarean deliveries’ prevalence was highest in Namibia (16.05%; 95% CI = 14.06–18.04) and lowest in Chad (1.32%; 95% CI = 0.91–1.73). For rural-urban disparities in caesarean delivery, the pooled prevalence of caesarean delivery was higher in urban areas (10.37%; 95% CI = 8.99–11.75) than rural areas (3.78%; 95% CI = 3.17-4.39) across the 28 countries. Approximately 81% of the rural–urban disparities in caesarean deliveries were attributable to the differences in child and maternal characteristics. Hence, if the child and maternal characteristics were levelled, more than half of the rural–urban inequality in caesarean deliveries would be reduced. Wealth index (39.2%), antenatal care attendance (13.4%), parity (12.8%), mother’s educational level (3.5%), and health insurance subscription (3.1%) explained approximately 72% of the rural–urban disparities in caesarean deliveries.

Conclusion
This study shows significant rural–urban disparities in caesarean deliveries, with the disparities being attributable to the differences in child and maternal characteristics: wealth index, parity, antenatal care attendance, mother’s educational level, and health insurance subscription. Policymakers in the included countries could focus and work on improving the socioeconomic status of rural-dwelling women as well as encouraging antenatal care attendance, women’s education, health insurance subscription, and family planning, particularly in rural areas.

Tools for self-management of obstetric fistula in low- and middle-income countries: a qualitative study exploring pre-implementation barriers and facilitators among global stakeholders

Background: Obstetric fistula, a debilitating maternal morbidity, occurs in contexts with poor access to and quality of emergency obstetric care, predominantly in sub-Saharan Africa. As many as two million women and girls suffer from fistula, which results in urinary incontinence, vulnerability to stigma for women and families, and economic consequences for the household and the healthcare system. Surgical repair, the gold standard for treatment, remains inaccessible to many and success is not guaranteed. Non-surgical, user-controlled fistula management options are not readily accessible, although some technologies, like insertable devices, have been found to have some level of feasibility and acceptability and provide short-term control over incontinence. As evidence for the effectiveness of tools to support self-management grows, the determinants of their implementation within various contexts remain unknown. The purpose of this qualitative study was to explore with key stakeholders, prior to implementation, those factors that could influence successful implementation of an innovation for self-management of obstetric fistula in a LMIC.

Methods: Stakeholders were purposefully identified from sectors that address the needs of women with obstetric fistula in sub-Saharan Africa: clinical care, academia, international health organizations, civil society, and government. Twenty-one key stakeholders were interviewed about their perceptions of innovations for fistula self-management and their implementation. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis of transcripts from recorded interviews. Analyses were carried out within Nvivo v.12. Deductive coding focused on constructs within the CFIR, then inductive coding identified additional constructs relevant for implementation.

Results: Potential facilitators to implementation included a clear tension for change for low-cost, accessible innovations for self-management and a relative advantage over existing tools. The development of partnerships and identification of champions could also support implementation. Barriers included the lack of evidence identifying the optimal beneficiary and the need for educational strategies that encourage acceptability among clinical providers. Inductive coding revealed an additional relevant construct of sustainability.

Conclusions: Effectiveness and implementation of non-surgical tools for fistula self-management should be further examined in LMICs. Future research could inform comprehensive fistula care to reduce vulnerability to stigma and improve quality of life.

Prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia: a multilevel fixed effects analysis

Background
An obstetric fistula is an inappropriate connection between the vagina, rectum, or bladder that results in faecal or urine incontinence. Young women from rural areas with poor socioeconomic situations and education are the majority of victims, which restricts their access to high-quality healthcare. Obstetric fistulas can have devastating effects on the physical health of affected women if they are not promptly treated. Inadequate awareness of the symptoms delays recognition of the problem, prompt reporting, and treatment. Women with poor awareness of the disorder are also more likely to develop complications, including mental health issues. Using data from a nationally representative survey, this study investigated the prevalence and factors associated with the awareness of obstetric fistula among women of reproductive age in The Gambia.

Methods
This study used population-based cross-sectional data from the 2019–2020 Gambia Demographic and Health survey. A total of 11823 reproductive-aged women were sampled for this study. Stata software version 16.0 was used for all statistical analyses. Obstetric fistula awareness was the outcome variable. Multilevel logistic regression models were fitted, and the results were presented as adjusted odds ratios (aOR) with statistical significance set at p < 0.05.

Results
The prevalence of obstetric fistula awareness was 12.81% (95%CI: 11.69, 14.12). Women aged 45–49 years (aOR = 2.17, 95%CI [1.54, 3.06]), married women (aOR = 1.39, 95%CI [1.04, 1.87]), those with higher education (aOR = 2.80, 95%CI [2.08, 3.79]), and women who worked as professionals or occupied managerial positions (aOR = 2.32, 95%CI [1.74, 3.10]) had higher odds of obstetric fistula awareness. Women who had ever terminated pregnancy (aOR = 1.224, 95%CI [1.06, 1.42]), those who listened to radio at least once a week (aOR = 1.20, 95%CI [1.02, 1.41]), ownership of a mobile phone (aOR = 1.20, 95%CI [1.01, 1.42]) and those who were within the richest wealth index (aOR = 1.39, 95%CI [1.03, 1.86]) had higher odds of obstetric fistula awareness.

Conclusion
Our findings have revealed inadequate awareness of obstetric fistula among women of reproductive-age in The Gambia. Obstetric fistulas can be mitigated by implementing well-planned public awareness initiatives at the institutional and community levels. We, therefore, recommend reproductive health education on obstetric fistula beyond the hospital setting to raise reproductive-age women's awareness.

International pediatric surgery partnerships in sub-Saharan Africa: a scoping literature review

Background
Sub-Saharan Africa (SSA) faces a critical shortage of pediatric surgical providers. International partnerships can play an important role in pediatric surgical capacity building but must be ethical and sustainable.

Objective
The purpose of this study is to perform a scoping literature review of international pediatric surgery partnerships in SSA from 2009 to 2019. We aim to categorize and critically assess past partnerships to aid in future capacity-building efforts.

Methods
We performed a scoping literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. We searched the PubMed and Embase databases for articles published from 2009 to 2019 using 24 keywords. Articles were selected according to inclusion criteria and assessed by two readers. Descriptive analyses of the data collected were conducted in Excel.

Results
A total of 2376 articles were identified. After duplicates were removed, 405 articles were screened. In total, 83 articles were assessed for eligibility, and 62 were included in the review. The most common partnership category was short-term surgical trip (28 articles, 45%). A total of 35 articles (56%) included education of host country providers as part of the partnership. Only 45% of partnerships included follow-up care, and 50% included postoperative outcomes when applicable.

Conclusions
To increase sustainability, more partnerships must include education of local health-care providers, and short-term surgical trips must be integrated into long-term partnerships. More partnerships need to report postoperative outcomes and ensure follow-up care. Educating peri-operative providers, training general surgeons in common pediatric procedures, and increasing telehealth use are other goals for future partnerships.