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. Supplementary Information: The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Impact of COVID-19 on Surgical Volume: Single-Center Experience from Addis Ababa, Ethiopia.

BACKGROUND: The COVID-19 pandemic has caused substantial disruptions to surgical-care delivery mainly due to diversion of available resources from surgical to COVID-19 care, reduced flow of patients, supply-chain interruptions and social distancing and restriction measures. The purpose of this study was to understand the impact of the pandemic on surgical volume in our hospital. METHODS: A descriptive cross-sectional study was done at Tikur Anbessa Specialized Hospital. A 2- year data was collected from March 2019 up to March 2021 from the operation theatre registration books. The data registry at the admission records office was also reviewed to extract the number pf patients on the elective surgery waiting list. Data were recorded, analyzed and reported using SPSS software package 26. RESULTS: The findings showed that there was a significant drop in surgical volume during the COVID-19 era. Surgical volume has dropped by 19% for emergency and by 32% for elective surgeries. COVID-19 test positivity of patients was identified as the single most important reason for elective operation cancellation during the first wave of the pandemic, contributing to as high as 85% of the reasons. CONCLUSION: The outcome of our study showed that COVID-19 has adversely affected elective and emergency surgical volume in our institution. This has also led to a dramatic increase in the surgical waiting list load. We recommend immediate surgical systems strengthening measures to re-build the surgical care ecosystem significantly affected by COVID-19. Surgical and anesthesia systems strengthening should be an integral part of pandemic preparedness and management.

Trends in Retention and Decay of Basic Surgical Skills: Evidence from Addis Ababa University, Ethiopia: A Prospective Case-Control Cohort Study.

INTRODUCTION: While prior studies have evaluated surgical skills simulation and retention in highly resourced environments, there is paucity of data on the retention of surgical skills taught in simulation laboratory to undergraduate students, and virtually none from low-resource settings. We aimed to evaluate the trends in retention/decay of surgical skills among medical students in Ethiopia and determine whether regular intervention in the form of intermittent skills testing can aid retention. METHODS: Forty-four final year medical students were randomly divided into two cohorts of 22 students each. All 44 were trained in surgical instrument identification, simple interrupted suturing and one-handed knot tying. A previously validated, standardized assessment was performed before training, immediately after training, and then at 6 weeks, 3 months, 6 months and 1 year for cohort 1, and before training, immediately after training, and at 6 months and 1 year for cohort 2. All areas learned were tested for general decay. RESULTS: The baseline mean scores of surgical skills were 3.8/30 for instrument identification, 3.3/15 for one-handed knot tying, and 1.35/15 for suturing. At the end of the training, mean scores improved to 26.6/30, 11.2/15 and 11.1/15 (instrument identification +599% and +772%, knot tying +447% and +417%, suturing +237% and +260%, respectively, for Cohort I and II). At 6 months and 1 year, there was a significant drop in all the three areas tested, especially in knot tying and suturing. There was no statistically significant difference between the two cohorts. CONCLUSIONS: While our surgical skills course is an effective means to teach surgical skills to medical students, there is significant decay in abilities after 6 months. Conducting regular assessments does not appear to have any effect in helping students retain these skills. We recommend such surgical skills training be conducted at appropriate intervals, such as just before internship, to prepare student for active surgical practice.

Incidence and patterns of surgical glove perforations: experience from Addis Ababa, Ethiopia.

BACKGROUND: Surgical glove perforation is a common event. The operating staff is not aware of the perforation until the procedure is complete, sometimes in as high as 70% of the incidences. Data from Ethiopia indicates that the surgical workforce suffers from a very surgery related accidents, however there is paucity of data regarding surgical glove perforation. The main objective is to describe the incidence and patterns of surgical glove perforation during surgical procedures and to compare the rates between emergency and elective surgeries at one of the main hospitals in Addis Ababa Ethiopia. METHODS: This is a prospective study, performed at the Minilik II referral hospital, Addis Ababa. All surgical gloves worn during all major surgical procedures (Emergency and Elective) from June 1-July 20, 2016 were collected and used for the study. Standardised visual and hydro insufflation techniques were used to test the gloves for perforations. Parameters recorded included type of procedure performed, number of perforations, localisation of perforation and the roles of the surgical team. RESULTS: A total of 2634 gloves were tested, 1588 from elective and 1026 from emergency procedures. The total rate of perforation in emergency procedures was 41.4%, while perforation in elective surgeries was 30.0%. A statistically significant difference (P < 0.05) was found in between emergency and elective surgeries. There were a very high rate of perforations of gloves among first surgeons 40.6% and scrub nurses 38.8% during elective procedures and among first surgeons (60.14%), and second assistants (53.0%) during emergency surgeries. Only 0.4% of inner gloves were perforated. The left hand, the left index finger and thumb were the most commonly perforated parts of the glove. Glove perforation rate was low among consultant surgeons than residents. CONCLUSIONS: Our reported perforation rate is higher than most publications, and this shows that the surgical workforce in Ethiopia is under a clear and present threat. Measures such as double gloving seems to have effectively prevented cutaneous blood exposure and thus should become a routine for all surgical procedures. Manufacturing related defects and faults in glove quality may also be contributing factors.

Injury surveillance in six hospitals of Addis Ababa, Ethiopia.

OBJECTIVE: This surveillance was initiated to see the hospital burden of injuries and as a pilot to test the injury surveillance integration in Ethiopia. BACKGROUND: Injury is becoming the major health problems in low income countries. Though it is important cause of mortality and morbidity, due attention is not given by the low-income countries. METHODS: This surveillance was conducted in six major hospitals of Addis Ababa, Ethiopia from February 1, 2003 to August 31, 2003. RESULTS: In total, 9000 patients related to injury visited the hospitals in this period. Majority of the injury patients visited the hospitals were males (73.2%) and the majority of the injury patients (72.5%) were in the age groups 15-44 years old. Struck/hit (45.7%) and road traffic injury (24.2%) were the leading causes of injury and falls with 11.5% follows the two. In terms of intent, 65.3% were unintentional and 31.8% were related to assaults. CONCLUSION: Injuries are important problems for Addis Ababa, Ethiopia and needs further community based study to determine the burden in the society. The surveillance system should be also integrated with the national health surveillance system.

Wound infection in Tikur Anbessa hospital, surgical department.

A prospective study of surgical wound infection has been conducted on 1754 surgical patients operated from January 1, 1999 to Dec 31, 1999 in Tikur Anbessa hospital. Demographic data and information on potential risk factors and the occurrence of wound infection in the first 30 days post operatively were collected using pretested data collection form. Among the patients 1162 (66.2%) were males and 592 (33.8%) were females. The age ranged from one day to 95 years with a mean of 30 (+/- 19) years. Seven hundred twenty eight (41.5%) wounds were classified as clean, 674 (38.4%) as clean-contaminated, 241 (13.7%) as contaminated and 111 (6.3%) as dirty and infected wounds. The overall wound infection rate was 14.8%. The infection rate for clean, clean-contaminated, contaminated and dirty and infected wounds were 8.0%, 14.8%, 22.0% and 44.2% respectively. The overall wound infection rates vary between 5.4% and 27.9% among consultant surgeons and it was 17.3% for residents. After adjusting for variation in patients condition and wound class, the infection rate of two surgeons was significantly higher, with odds ratio (OR) of 2.3 and 2.9. Shaving in the ward and use of drains were associated with a statistically significantly higher infection rate after adjusting for all factors considered in the study, with OR of 1.9 & 2.3 respectively. Preoperative antibiotics were found to be highly protective after multiple stepwise regressions with OR of 0.33. Post operative hospital stay and mortality were significantly higher in patients who had wound infection after adjusting for potentially confounding variables. It is concluded that the infection rate are much higher than the acceptable standard and this underscores the need for establishing hospital infection control system. Minimizing the use of drains, avoiding preoperative shaving, judicious use of preoperative antibiotics and meticulous surgical technique should be part of the immediate strategy to reduce wound infection rate.

Clinical value of uroflowmentry in selected cases of bladder outlet obstruction.

Fifteen patients with Benign Prostatic Hyperplasia (BPH), 42 urethral stricture patients, and 34 controls were included in this study to describe outflowmetry findings at Tikur Anbessa Hospital in Addis Abeba from April to August 2000. Normal values for maximum and average urine flow rates were determined Uroflowmetry findings in BPH and urethral stricture were compared with normal subjects. The average age for BPH, urethral stricture, and controls were 63.3 (SD +/- 10.3), 38.4 (SD +/- 12.4), and 28.5 (SD +/- 7.9) respectively. The mean maximum flow rates for normal subjects was 22.7 ml/sec (range 15 to 42 ml/sec) and mean average flow rates 14.7 ml/sec (range 9 to 25 ml/sec). Mean maximum flow rate for BPH and Urethral Stricture were 11.5 (SD +/- 8.2) and 8.7 (SD +/- 6.5) ml/sec respectively. For urethral stricture maximum flow rate had sensitivity and specificity of 91% and 85% respectively. For BPH sensitivity was 100% and specificity 80%. Normal values are set for the study population. Uroflowmetry has high sensitivity and specificity. It can widely be used in routine-evaluation of BPH and urethral stricture patients.

International prostate symptom score as a clinical outcome measure for Ethiopian patients with urethral stricture.

Eighty-four urethral stricture patients and 73 controls were studied prospectively over a 6 months period in Tikur Anbessa Hospital from April to August 2000. The purpose of the study was to evaluate the use of International Prostate Symptom Score (IPSS) as an outcome measurement instrument for urethral stricture patients in Ethiopia. The Amharic translation of IPSS (IPSS Amh) was used in this study. Internal consistency was 0.91. Construct validity was 0.73. Test-retest reliability was 0.95. Sensitivity and specificity were 76% and 71% respectively. In conclusion the IPSS Amh was found to be valid for use in urethral stricture patients in Ethiopia. We recommend the wide use of this cheap and easily available clinical measurement instrument.

Trauma registry in Tikur Anbessa Hospital, Addis Ababa, Ethiopia.

A simplified trauma registry was tested in Tikur anbessa hospital, with the aim of obtaining preliminary data on the patterns and magnitude of injuries and establishing the basis towards surveillance system. All injured patients presented to the surgical and pediatric emergency department between January 1, 1999 and June 31, 1999 were included. Interns completed the registry forms, which include demographic, injury event specific, severity and outcome data. The severity was assessed by new scoring system, Kampla Trauma Score (KTS). Among the 3822 injured patients 2869(75%) were males and 953(25%) were females and 80% were below the age of 40 years. 77% of the injuries were unintentional and motor vehicle injuries accounted for 41% of all causes among which 93% of them were pedestrians. Accidental fall and interpersonal assault accounted for 21% and 20% respectively. Admitted cases were 11.6%, while 20 (.5%) died at the outpatient department with the overall mortality of 1.47%. Though burn and gunshot accounted only for 6%, the case fatality rate was highest (4%) accounting for 20% of all deaths. The magnitude of fatal injuries is underestimated and the pattern of injuries may only reflect the situation in the big cities. Motor vehicle injuries, especially pedestrian injuries are serious problem in Addis as seen in patients in Tikur Anbessa hospital and require further situational studies and urgent intervention. Establishing hospital based simplified injury surveillance system is possible in Ethiopia and it is essential to asses the magnitude of the problem and identify priority area for injury prevention and control.