Altitude-Related Disorders on Mount Kilimanjaro, Tanzania: Two-Year Survey in a Local Referral Center.

INTRODUCTION: A significant number of climbers on Mount Kilimanjaro are affected by altitude-related disorders. The aim of this study was to determine the main causes of morbidity and mortality in a representative cohort of climbers based on local hospital records. METHODS: We conducted a 2-y retrospective chart review of all patients presenting to the main referral hospital in the region after a climb on Mount Kilimanjaro, including all relevant records and referrals for postmortem studies. RESULTS: We identified 62 climbers who presented to the hospital: 47 inpatients and 15 outpatients. Fifty-six presented with high altitude illness, which included acute mountain sickness (n=8; 14%), high altitude pulmonary edema (HAPE) (n=30; 54%), high altitude cerebral edema (HACE) (n=7; 12%), and combined HAPE/HACE (n=11; 20%). The mean altitude of symptom onset ranged from 4600±750 m for HAPE to 5000±430 m for HAPE/HACE. The vast majority of inpatients (n=41; 87%) were improved on discharge. Twenty-one deceased climbers, most having died while climbing (n=17; 81%), underwent postmortem evaluation. Causes of death were HAPE (n=16; 76%), HAPE/HACE (n=3; 14%), trauma (1), and cardiopulmonary (1). CONCLUSIONS: HAPE was the main cause of death during climbing as well as for hospital admissions. The vast majority of climbers who presented to hospital made a full recovery.

An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.

BACKGROUND: Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. METHODS: We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. RESULTS: Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. CONCLUSIONS: Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.

Injury patients' perceptions of drink-driving: A qualitative assessment of drink-driving behavior in Moshi, Tanzania.

BACKGROUND: Globally, about 2.3 billion people are current alcohol drinkers, and 283 million have an alcohol use disorder. Alcohol use while driving is a major contributor to road traffic injuries (RTI). We need to understand the culture and perception of drink-driving in this setting to understand why people continue to drink drive and allow policymakers to develop more effective ways to address drink-driving behavior. This study aims to qualitatively determine what injury patients, their families, and community advisory board members in Tanzania believe about drink-driving to help inform policies to address this problem. METHODS: The semi-structured focus group was designed based on the grounded theory and assessed using thematic analysis. Focus groups participants were a convenience sample of injury patients, their families, and community advisory board (CAB) members. Analysis was iterative throughout the study. All transcripts were coded using a thematic narrative approach. Representative quotes for each theme were then selected based on comparative analysis of coding with input from research team members. RESULTS: A total of ten focus groups were conducted (4 patient, 4 family, and 2 CAB) with a total of 104 participants (37 females and 67 males). The normalization of drinking among drivers has allowed this behavior to become ingrained in the culture. Participants expressed notions that passengers are responsible for their own safety, rather than drivers being responsible for their passengers. Most participants believe it is a citizen's duty to inform the police of suspected drink-driving, however there were differing opinions about how effective informed police officers can be in practice. Focus group discussions between all three population types highlighted major themes of 'drinking is ingrained in boda boda driver culture', 'individuals have a personal responsibility to address drink-driving', and a 'police enforcement on drink-driving is necessary'. CONCLUSIONS: Normalization of drink-driving in commercial driver culture creates a dangerous environment for passengers which can be mitigated by education and health promotion. As most passengers already take personal responsibility for their own road traffic safety, they may be likely to make use of safe ride options, if available. While legislation is in place against drink-driving, police officers need to be empowered with appropriate training and funding to enforce them.

Alcohol stigma as it relates to drinking behaviors and perceptions of drink drivers: A mixed method study in Moshi, Tanzania.

BACKGROUND: Alcohol is a leading risk factor for road traffic injury in low- and middle-income countries, such as Tanzania. This research seeks to explore the drinking patterns, perceptions, and stigma of drink driving behavior of injury patients at Kilimanjaro Christian Medical Center in Moshi, Tanzania. METHODS: This mixed methods study incorporated the Perceived Alcohol Stigma (PAS), an additive Likert scale, and the Alcohol Use Disorders Identification Test (AUDIT). Results are reported as medians with IQRs. Additionally, focus groups with injury patients, their families, and community members (n = 104) were conducted and analyzed in pairs using an inductive thematic content analysis approach. RESULTS: Those who self-reported driving after ingesting 3 or more alcoholic drinks had a median AUDIT score (median = 11.0) significantly higher than those who denied drink driving (median = 5.5, p < 0.01). The PAS showed a high overall stigma against those who use alcohol but differed for drink drivers, drinkers, and abstainers (median = 20.8, 23.9, 34.9, p < 0.01). Thematic content analysis highlighted a 'disapproving of drink drivers', that 'problematic drinking is a drinking behavior which negatively affects others', and a 'passiveness toward drinking and drink driving'. CONCLUSIONS: Stigma against those who use alcohol is present in Tanzania. Perceived stigma is significantly lower among those who drink drive than those who do not. Overall, there appears to be a community-wide disapproval of drinking and driving, which is coupled with feeling unable to change this risky behavior.

Perceptions of alcohol use among injury patients and their family members in Tanzanian society.

Alcohol is one of the leading causes of death and disability worldwide. Rates of alcohol abuse in Moshi, Tanzania, are about 2.5 times higher than the Tanzanian average. We sought to qualitatively assess the perceptions of alcohol use among injury patients in Moshi, including availability, consumption patterns, abuse, and treatments. Participants were Emergency Department injury patients, their families, and community advisory board members. Participants were included if they were ≥18 years of age, a patient or patient's family member seeking care at the Kilimanjaro Christian Medical Center Emergency Department, Moshi, Tanzania, for an acute injury, clinically sober at the time of enrollment, medically stable, able to communicate in Swahili and consented to participate. Focus group discussions were audiotaped, transcribed, translated, and analyzed in parallel using an inductive thematic content analysis approach. Resultant themes were then reanalyzed to ensure internal homogeneity and external heterogeneity. Fourteen focus group discussions, with a total of 104 participants (40 patients, 50 family members, 14 community advisory board members), were conducted. Major themes resulting from the analysis included: 1) Early/repeated exposure; 2) Moderate use as a social norm with positive attributes; 3) Complications of abuse are widely stigmatized; and 4) Limited knowledge of availability of treatment. Our findings suggest that, among our unique injury population and their families, despite the normalization of alcohol-related behaviors, there is strong stigma toward complications stemming from excess alcohol use. Overall, resources for alcohol treatment and cessation, although broadly desired, are unknown to the injury population.

Cross-cultural adaptation and psychometric properties of the MMSE and MoCA questionnaires in Tanzanian Swahili for a traumatic brain injury population.

BACKGROUND: Traumatic Brain Injury (TBI) is the most common cause of injury-related death and disability globally, and a common sequelae is cognitive impairment. Addressing post-TBI cognitive deficits is crucial because they affect rehabilitation outcomes, but doing this requires valid and reliable cognitive assessment measures. However, no such instrument has been validated in Tanzania's TBI population. Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are two commonly used instruments to measure cognitive impairment, and there have been a few studies reporting their use in post-TBI cognitive assessment. Our aim was to report the psychometric properties of the Swahili version of both scales amongst the TBI population in Tanzania. METHODS: A cross-cultural adaptation committee participated in the translation and content validation process for both questionnaires. Our patient sample consisted of 192 adults with TBI who were admitted to Kilimanjaro Christian Medical Center (KCMC) in Tanzania. Confirmatory factor analysis, reliability and external validity were evaluated. RESULTS: MoCA showed adequate factor loadings (values > 0.50 for all items except items 7 & 10) and adequate reliability (values > 0.70). Factor loadings for most of the MMSE items were below 0.5 and internal consistency was medium (< 0.7). Polychoric correlation between MMSE and MoCA was strong, positive and statistically significant (r = 0.68, p = 0.001); correlation with the cognitive subscale of FIM indicated moderately positive relationships - MMSE (r = 0.35, p = 0.001) and MoCA (r = 0.43, p = 0.001). CONCLUSIONS: With the exception of the language and memory items, MoCA is a valid and reliable instrument for cognitive impairment screening in Tanzania's adult TBI population. On the other hand, MMSE does not appear to be an appropriate tool in this patient group, but its positive correlations with MoCA and cFIM indicate similar theoretical concepts. Both instruments require further validation studies to prove their predictive ability for screening cognitive impairment before they are considered suitable for clinical use.

Injury prevalence and safety habits of boda boda drivers in Moshi, Tanzania: A mixed methods study.

BACKGROUND: Traffic crashes are a major cause of global morbidity and mortality disproportionately affecting low- and middle-income countries (LMICs). Motorcycle taxi (boda boda) drivers are particularly vulnerable because they are exposed to traffic risks with limited safety equipment. This study aims to characterize injury prevalence and safety habits among boda boda drivers, as well as ways to improve road traffic safety in LMICs. METHODS: A cross-sectional mixed methods study was conducted with 300 boda boda drivers between 24 March and 3 April 2014 in urban Moshi, Tanzania. A convenience sample of participants was drawn from 25 of 58 registered boda boda stands and 2 of 31 unregistered stands. Data were analyzed using R, and content thematic analysis was performed and agreed upon by three investigators. Logistic regression models were used to evaluate the association between boda boda characteristics and injury risk. RESULTS: In total, 300 drivers participated, of whom 148 (49.3%) had experienced a crash during their lifetime, and 114 (77.0%) sustained at least one injury. Only 27 of those injured (23.4%) were hospitalized. Of all participants, 220 (73.3%) reported consistent helmet usage, despite 285 participants (95.0%) agreeing that helmet usage reduces injury severity. From the 280 helmets observed, 231 (82.5%) were either damaged or fit improperly. Having a cracked helmet was associated with higher risk of being involved in a traffic crash. Owning a helmet with a proper fit was associated with reduced risk for a traffic crash (OR = 0.06) and road traffic injuries (OR = 0.07). A thematic analysis of boda boda drivers' suggestions to increase road safety identified four intervention areas: 1) roadway infrastructure and traffic regulation, 2) road user attitudes and safe driving behaviors, 3) education and training, and 4) law enforcement. CONCLUSION: Our study demonstrates boda boda drivers' safety behaviors and identifies four intervention areas that can be leveraged to increase overall road traffic safety. Unfortunately, while boda boda drivers are aware of ways to improve safety, adherence to safety habits remains low. Successful multi-sectoral interventions are needed to improve road safety for boda boda drivers in Tanzania.

Cross-cultural adaptation and psychometric properties of the Kessler Scale of Psychological Distress to a traumatic brain injury population in Swahili and the Tanzanian Setting.

BACKGROUND: To evaluate the psychometric properties of a Swahili version of the Kessler Psychological Distress scale in an injury population in Tanzania. METHODS: Swahili version of the Kessler Psychological Distress scale was developed by translation and back-translation by a panel of native speakers of both English and Swahili. The translated instruments were administered to a sample of Tanzanian adults from a traumatic brain injury registry. The content validity, construct validity, reliability, internal structure, and external reliability were analyzed using standard statistical methods. RESULTS: Both translated versions of the Kessler Psychological Distress scale were found to be reliable (>0.85) for all tested versions. Confirmatory factor analysis of one and two factor solution showed adequate results. Kessler Psychological Distress scale scores were strongly correlated to depression and quality of life (R>0.50). CONCLUSIONS: This paper presents the first Swahili adaptations of the Kessler Psychological Distress scale as well as the first validation of these questionnaires in Tanzania. The instrument was found to have acceptable psychometric properties, resulting in a new useful tool for medical and social research in this setting.

Perceived barriers by health care providers for screening and management of excessive alcohol use in an emergency department of a low-income country.

Annually, alcohol causes 3.3 million deaths; countless more alcohol-related injury patients are treated in emergency departments (EDs) worldwide. Studies show that alcohol-related injury patients reduce their at-risk alcohol-use behavior with a brief negotiational interview (BNI) in the ED. This project aims to identify potential perceived barriers to implementing a BNI in Tanzania. A knowledge, attitude, and practice questionnaire was piloted and administered to all emergency department health care practitioners, including physicians, advanced medical officers, and nurses. The questionnaire included the Perceived Alcohol Stigma (PAS) Scale. The survey was self-administered in English, the language of health care instruction, with a Swahili translation available if preferred. Data were analyzed with relative and absolute frequencies and Spearman's correlation. Thirty-four (100%) health care practitioners completed the survey. Our results found positive attitudes toward addressing alcohol misuse (88%), but very poor knowledge of recommended alcohol-use limits (24%). Participants were willing to discuss alcohol use (88%) and to screen (71%) for alcohol-use disorders. Most health care practitioners report significant stigma against those with alcohol-use disorders (39% discrimination, 53% devaluation, 71% either). Counseling patients about high-risk alcohol use was directly and positively associated with at-risk alcohol and counseling education and believing it was common to ask patients about tobacco and alcohol use; it was negatively associated with believing it was 'not my role' or that knowing about alcohol use 'won't make a difference'. Stigma was negatively and indirectly associated with counseling patients. In conclusion, in an ED in Tanzania, health care practitioners have positive attitudes toward addressing at-risk alcohol use, and endorsed having training in alcohol misuse in school. Unfortunately, participants did not demonstrate knowledge of recommended alcohol limit guidelines. Similarly, among practitioners, there is a significant discrimination and devaluation stigma against those who misuse alcohol. These factors must be addressed prior to a successful implementation of an alcohol harm reduction intervention.

The impact of alcohol among injury patients in Moshi, Tanzania: a nested case-crossover study.

BACKGROUND: Globally, alcohol is responsible for 3.3 million deaths annually and contributes to 5.9% of the overall global burden of disease. In Sub-Saharan Africa, alcohol is the leading avoidable risk factor accounting for a substantial portion of death and disability. This project aimed to determine the proportion of injuries related to alcohol and the increased risk of injury due to alcohol among injury patients seeking care at the emergency department (ED) of Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. METHODS: A representative cross-sectional sample of adult patients presenting to the KCMC ED with acute injury were enrolled in this study with a nested case-crossover design. Patient demographics, injury characteristics, and severity as well as alcohol use behaviors were collected. Alcohol breathalyzers were administered to the enrolled patients. Data on activities and alcohol use were collected for the time period 6 h prior to injury and two control periods: 24-30 h prior to injury and 1 week prior to injury. RESULTS: During 47 weeks of data collection, 24,070 patients were screened, of which 2164 suffered injuries, and 516 met the inclusion and exclusion criteria, consented to participate, and had complete data. Of the study participants, 76% were male, and 30% tested positive for alcohol on arrival to the ED. Alcohol use was associated with being male and being employed. Alcohol use was associated with an increased risk of injury (OR 5.71; 95% CI 3.84-8.50), and specifically road traffic injuries were associated with the highest odds of injury with alcohol use (OR 6.53, 95% CI 3.98-10.71). For all injuries and road traffic injuries specifically, we found an increase in the odds of injury with an incremental increase in the dose of alcohol. CONCLUSIONS: At KCMC in Moshi, Tanzania, 3 of 10 injury patients tested positive for alcohol on presentation for care. Similarly, alcohol use conveys an increased risk for injury in this setting. Evidence-based prevention strategies for alcohol-related injuries need to be implemented to reduce alcohol misuse and alcohol-related injuries.

Built environment analysis for road traffic hotspot locations in Moshi, Tanzania.

Road traffic injuries (RTIs) cause significant morbidity and mortality in low- and middle-income countries. Investigation of high risk areas for RTIs is needed to guide improvements. This study provides built environmental analysis of road traffic crash hotspots within Moshi, Tanzania. Spatial analysis of police data identified 36 hotspots. Qualitative comparative analysis revealed 40% of crash sites were on local roads without night lighting and increased motorcycle density. Paved narrow roads represented 26% of hotspots and 13% were unpaved roads with uneven roadsides. Roadside unevenness was more predominate in low risk [n = 19, (90.5%)] than high risk sites [n = 7 (46.7%)]. Both low [n = 6 (28.6%)] and high risk [n = 1 (6.7%)] sites had minimal signage. All sites had informal pedestrian pathways. Little variability between risk sites suggests hazardous conditions are widespread. Findings suggest improvement in municipal infrastructure, signage and enforcement is needed to reduce RTI burden.

Cross-Cultural Adaptation and Psychometric Properties of the AUDIT and CAGE Questionnaires in Tanzanian Swahili for a Traumatic Brain Injury Population.

AIMS: To develop Swahili versions of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE questionnaires and evaluate their psychometric properties in a traumatic brain injury (TBI) population in Tanzania. METHODS: Swahili versions of the AUDIT and CAGE were developed through translation and back-translation by a panel of native speakers of both English and Swahili. The translated instruments were administered to a sample of Tanzanian adults from a TBI registry. The validity and reliability were analyzed using standard statistical methods. RESULTS: The translated versions of both the AUDIT and CAGE questionnaires were found to have excellent language clarity and domain coherence. Reliability was acceptable (>0.85) for all tested versions. Confirmatory factor analysis of one, two and three factor solution for the AUDIT and one factor solution for the CAGE showed adequate results. AUDIT and CAGE scores were strongly correlated to each other (R > 0.80), and AUDIT scores were significantly lower in non-drinkers compared to drinkers. CONCLUSIONS: This article presents the first Swahili and Tanzanian adaptations of the AUDIT and CAGE instruments as well as the first validation of these questionnaires with TBI patients. Both instruments were found to have acceptable psychometric properties, resulting in two new useful tools for medical and social research in this setting.

The epidemiology and hotspots of road traffic injuries in Moshi, Tanzania: An observational study.

Road traffic injuries (RTIs) continue to increase with the proliferation of motor vehicles, especially in low-income countries where safe road infrastructure is lacking. Knowing where and why RTIs occur would allow for increased safety and prevention planning. In this study, police records of 300 motor vehicle collisions which occurred between February 2013 and January 2014 in Moshi, Tanzania were reviewed. Analysis of variables including victim age, gender, type of collision, conditions, and use of safety equipment were analyzed. Geographic information system (GIS) analysis was performed to identify areas with the most collisions. Most injuries occurred at four intersections on two main corridor. Car crashes represented 48% of reports while motorcycle collisions were 35% of reports. Victims were predominantly male. The majority (64%) of RTI victims in cars used seatbelts while only 43% of motorcyclists wore helmets; none of those who used the helmet or seatbelt suffered a grievous injury. These data demonstrate that RTIs in Moshi occur in predictable high traffic locations. RTIs injure victims of all backgrounds and safety equipment is not universally utilized. More investment is needed in improved data collection methods, and a greater emphasis on intersection safety is needed to reduce these preventable injuries.

A prospective registry evaluating the epidemiology and clinical care of traumatic brain injury patients presenting to a regional referral hospital in Moshi, Tanzania: challenges and the way forward.

Traumatic brain injury (TBI) is the most common cause of death and disability globally disproportionately affecting low- and middle-income countries where increasing injury rates are compounded by limited quality care. The objective of this study is to describe quality of care for TBI patients who presented to Kilimanjaro Christian Medical Center, Moshi, Tanzania. We evaluated a prospective quality improvement TBI registry that enrolled consecutive patients with acute TBI. Descriptive statistics and qualitative comparative analysis was performed. Overall, 893 TBI patients were enrolled during the study period, with a mean age of 32.1 years and who were mostly (80%) male. 12.9% suffered severe TBI (GCS < 9). Most injuries were road traffic (66%) especially motorcyclists (49%) and 26.8% were alcohol related. One intubation occurred, and 22.9% of hypoxic patients received oxygen. Severe TBI mortality was 47%. TBI affects men 15-45 years old in traffic crashes with high mortality for severe TBI (47%) patients. Care addressing secondary injury, hypoxemia, and hypotension is limited.