Disparities in injury mortality between Uganda and the United States: comparative analysis of a neglected disease

Background  

The burden of global injury-related deaths predominantly affects developing countries, which have little infrastructure to evaluate these disparities. We describe injury-related mortality patterns in Kampala, Uganda and compare them with data from the United States and San Francisco (SF), California.     

Surgical Capacity Building in Uganda Through Twinning, Technology, and Training Camps

Background  

Neurosurgical capacity is extremely deficient in East African countries where 27 neurosurgeons serve more than 250 million people. To build capacity, the Duke University Medical Center and New Mulago Hospital in Uganda applied a two-pronged twinning approach that placed usable surplus equipment in a developing country’s National Hospital, combined with dedicated comprehensive surgical training camps.     

Selenium Deficiency a Factor in Endemic Goiter Persistence in Sub-Saharan Africa

Background  

Goiter is still common in Uganda, despite the present iodized salt coverage of at least 95%. Where there is endemic goiter after adequate iodine supplementation, selenium deficiency could be a factor for the continued occurrence of goiter. The objectives of the present study, therefore, were to determine the serum selenium levels among goitrous patients and nongoitrous controls and to determine the association between goiter and selenium levels among these patients.     

Low urine pH and acid excretion do not predict bone fractures or the loss of bone mineral density: a prospective cohort study

Background  

The acid-ash hypothesis, the alkaline diet, and related products are marketed to the general public. Websites, lay literature, and direct mail marketing encourage people to measure their urine pH to assess their health status and their risk of osteoporosis.     

Divided by a lack of common language? - a qualitative study exploring the use of language by health professionals treating back pain

Background  

The importance of using a common language when communicating to others about back pain is acknowledged in the literature. There are broadly three areas where difficulties in communication about back pain arise. Firstly, patients seeking information from health care professionals can experience difficulties understanding them and the medical literature; secondly, misunderstandings among health professionals concerning terminology can arise. Thirdly, the lack of standardised definitions for back pain terms can make comparison of research studies problematic. This study aims to explore the meanings and issues surrounding the use of existing medical terms for back pain from the perspective of health care professionals, lay people who have consulted health care practitioners for back pain and lay people who have not seen a health care professional regarding back pain.     

Between a rock and a hard place: stigma and the desire to have children among people living with HIV in northern Uganda

Background

HIV-related stigma, among other factors, has been shown to have an impact on the desire to have children among people living with HIV (PLHIV). Our objective was to explore the experiences of HIV-related stigma among PLHIV in post-conflict northern Uganda, a region of high HIV prevalence, high infant and child mortality and low contraception use, and to describe how stigma affected the desires of PLHIV to have children in the future.

Methods

Semi-structured interviews were conducted with 26 PLHIV in Gulu district, northern Uganda. The interviews, conducted in Luo, the local language, were audio recorded, transcribed and then translated into English. Thematic data analysis was undertaken using NVivo8 and was underpinned by the “Conceptual Model of HIV/AIDS Stigma”.

Results

HIV-related stigma continues to affect the quality of life of PLHIV in Gulu district, northern Uganda, and also influences PLHIV''s desire to have children. PLHIV in northern Uganda continue to experience stigma in various forms, including internal stigma and verbal abuse from community members. While many PLHIV desire to have children and are strongly influenced by several factors including societal and cultural obligations, stigma and discrimination also affect this desire. Several dimensions of stigma, such as types of stigma (received, internal and associated stigma), stigmatizing behaviours (abusing and desertion) and agents of stigmatization (families, communities and health systems), either directly, or indirectly, enhanced or reduced PLHIV''s desire to have more children.

Conclusion

The social-cultural context within which PLHIV continue to desire to have children must be better understood by all health professionals who hope to improve the quality of PLHIV''s lives. By delineating the stigma process, the paper proposes interventions for reducing stigmatization of PLHIV in northern Uganda in order to improve the quality of life and health outcomes for PLHIV and their children.     

Access to Safe,Timely, and Affordable Surgical Care in Uganda: A Stratified Randomized Evaluation of Nationwide Public Sector Surgical Capacity and Core Surgical Indicators

Background

Access to safe surgery is critical to health, welfare, and economic development. In 2015, the Lancet Commission on Global Surgery recommended that all countries collect surgical indicators to lend insight into improving surgical care. No nationwide high-quality data exist for these metrics in Uganda.

Methods

A standardized quantitative hospital assessment and a semi-structured interview were administered to key stakeholders at 17 randomly selected public hospitals. Hospital walk-throughs and retrospective reviews of operative logbooks were completed.

Results

This study captured information for public hospitals serving 64.0% of Uganda’s population. On average, <25% of the population had 2 h access to a surgically capable facility. Hospitals averaged 257 beds/facilities and there were 0.2 operating rooms per 100,000 people. Annual surgical volume was 144.5 cases per 100,000 people per year. Surgical, anesthetic, and obstetrician physician workforce density was 0.3 per 100,000 people. Most hospitals reported having electricity, oxygen, and blood available more than half the time and running water available at least three quarters of the time. In total, 93.8% of facilities never had access to a CT scan. Sterile gloves, nasogastric tubes, and Foley catheters were frequently unavailable. Uniform outcome reporting does not exist, and the WHO safe surgery checklist is not utilized.

Conclusion

The Ugandan public hospital system does not meet LCoGS targets for surgical access, workforce, or surgical volume. Critical policy and programmatic developments are essential to build surgical capacity and facilitate provision of safe, timely, and affordable surgical care. Surgery must become a public health priority in Uganda and other low resource settings.

     

Surgery and Anesthesia Capacity-Building in Resource-Poor Settings: Description of an Ongoing Academic Partnership in Uganda

Background

Surgery and perioperative care have been neglected in the arena of global health despite evidence of cost-effectiveness and the growing, substantial burden of surgical conditions. Various approaches to address the surgical disease crisis have been reported. This article describes the strategy of Global Partners in Anesthesia and Surgery (GPAS), an academically based, capacity-building collaboration between North American and Ugandan teaching institutions.

Methods

The collaboration’s projects shift away from the trainee exchange, equipment donation, and clinical service delivery models. Instead, it focuses on three locally identified objectives to improve surgical and perioperative care capacity in Uganda: workforce expansion, research, collaboration.

Results

Recruitment programs from 2007 to 2011 helped increase the number of surgery and anesthesia trainees at Mulago Hospital (Kampala, Uganda) from 20 to 40 and 2 to 19, respectively. All sponsored trainees successfully graduated and remained in the region. Postgraduate academic positions were created and filled to promote workforce retention. A local research agenda was developed, more than 15 collaborative, peer-reviewed papers have been published, and the first competitive research grant for a principal investigator in the Department of Surgery at Mulago was obtained. A local projects coordinator position and an annual conference were created and jointly funded by partnering international efforts to promote collaboration.

Conclusions

Sub-Saharan Africa has profound unmet needs in surgery and perioperative care. This academically based model helped increase recruitment of trainees, expanded local research, and strengthened stakeholder collaboration in Uganda. Further analysis is underway to determine the impact on surgical disease burden and other important outcome measures.     

Herzdruckmassage im Rahmen der Laienreanimation

Background

The quality of chest compressions and early defibrillation are paramount in cardiopulmonary resuscitation (CPR). Whether real-time feedback devices may improve CPR efforts in lay person CPR is unclear.

Material and methods

Prospective randomized studies were carried out to test the influence of the electronic real-time feedback device PocketCPR? on the quality of chest compression by lay person CPR training in a mock-up cardiac arrest scenario. Altogether 42 inexperienced lay persons were randomized into 2 groups (groups A and B). The quality of chest compressions was analyzed with respect to depth and frequency in a cross-over design.

Results

PocketCPR? improved mean chest compression depth significantly (p=0.029) solely in one of both groups (44±7 versus 41±10 mm). However, both groups achieved recommended compression depths between 38–51 mm independent of device application. Also mean chest compression frequency was improved significantly (p=0.001) in one group only (100±21 versus 115±21 per min). There was no demonstrable significant potential learning effect through the application of the feedback device.

Conclusion

Real-time feedback devices do not ensure a consistent improvement of chest compression quality during mock-up lay person CPR training. Additional studies are needed to investigate potential effects for trained health care professionals.     

Lay First Responder Training in Eastern Uganda: Leveraging Transportation Infrastructure to Build an Effective Prehospital Emergency Care Training Program

Background

Though road traffic injuries (RTIs) are a major cause of mortality in East Africa, few countries have emergency medical services. The aim was to create a sustainable and efficient prehospital lay first responder program, creating a system with lay first responders spread through the 53 motorcycle taxi stages of Iganga Municipality.

Methods

One hundred and fifty-four motorcycle taxi riders were taught a first aid curriculum in partnership with a local Red Cross first aid trainer and provided with a first aid kit following WHO guidelines for basic first aid. Pre- and post-survey tests measured first aid knowledge improvement over the course. Post-implementation incident report forms were collected from lay first responders after each patient encounter over 6 months. Follow-up interviews were conducted with 110 of 154 trainees, 9 months post-training.

Results

Improvement was measured across all five major first aid categories: bleeding control (56.9 vs. 79.7%), scene management (37.6 vs. 59.5%), airway and breathing (43.4 vs. 51.6%), recovery position (13.1 vs. 43.4%), and victim transport (88.2 vs. 94.3%). From the incident report findings, first responders treated 250 victims (82.8% RTI related) and encountered 24 deaths (9.6% of victims). Of the first aid skills, bleeding control and bandaging was used most often (55.2% of encounters). Lay first responders provided transport in 48.3% of encounters. Of 110 lay first responders surveyed, 70 of 76 who had used at least one skill felt “confident” in the care they provided.

Conclusion

A prehospital care system composed of lay first responders can be developed leveraging existing transport organizations, offering a scalable alternative for LMICs, demonstrating usefulness in practice and measurable educational improvements in trauma skills for non-clinical lay responders.

     

Pediatric surgical camps as one model of global surgical partnership: A Way Forward

Background/Purpose

A uniquely Ugandan method of holding surgical “camps” has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership.

Methods

We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery.

Results

Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian–Ugandan pediatric surgery teaching alliance.

Conclusion

Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.     

When Surgical Resources are Severely Constrained,Who Receives Care? Determinants of Access to Orthopaedic Trauma Surgery in Uganda

Background

In low- and middle-income countries, the volume of traumatic injuries requiring orthopaedic intervention routinely exceeds the capacity of available surgical resources. The objective of this study was to identify predictors of surgical care for lower extremity fracture patients at a high-demand, resource-limited public hospital in Uganda.

Methods

Skeletally mature patients admitted with the intention of definitive surgical treatment of an isolated tibia or femur fractures to the national referral hospital in Uganda were recruited to participate in this study. Demographic, socioeconomic, and clinical data were collected through participant interviews at the time of injury and 6 months post-injury. Social capital (use of social networks to gain access to surgery), financial leveraging, and ethnicity were also included as variables in this analysis. A probit estimation model was used to identify independent and interactive predictors of surgical treatment.

Results

Of the 64 patients included in the final analysis, the majority of participants were male (83%), with a mean age of 40.6, and were injured in a motor vehicle accident (77%). Due to resource constraints, only 58% of participants received surgical care. The use of social capital and femur fractures were identified as significant predictors of receiving surgical treatment, with social capital emerging as the strongest predictor of access to surgery (p < 0.05).

Conclusion

Limited infrastructure, trained personnel, and surgical supplies rations access to surgical care. In this environment, participants with advantageous social connections were able to self-advocate for surgery where demand for these services greatly exceeded available resources.

     

Injury in Kampala,Uganda: 6 years later

Background

Trauma remains a tremendous cause of morbidity and mortality in most countries. The objective of our study was to describe injury from trauma at the major referral hospital in Uganda over a 1-year period.

Methods

Trauma registry forms have been completed for all trauma patients seen between August 2004 and July 2005 at the casualty department of Mulago Hospital in Kampala, Uganda. We also obtained 2-week follow-up data, and we compared these data with 1998 data from the same institution.

Results

In all, 3778 patients were entered into the database, with complete data available for 93.5% of patients. Patients had a mean age of 26 (standard deviation [SD] 12) years, and 75% of patients were male. The mean Kampala Trauma Score (KTS) was 9.1 (SD 1). We classified injuries as mild (82%; KTS 9–10), moderate (14%; KTS 7–8) and severe (4%; KTS ≤ 6). On arrival, 57% of patients were treated and sent home, 41.6% were admitted and 0.4% died in the casualty department. At 2-week follow-up, 85% were discharged, 12% were still in hospital and 2.7% had died. Causes of injury included road traffic collisions (50%), blunt force (15%), falls (10%), stab wounds (9%), animal bites (7%), burns (6%) and gunshot wounds (1%). Causes of mortality were road traffic collisions (61%), burns (15%), blunt trauma (8.6%), falls (6.5%), stabs/cuts (5.4%) and other (3.3%). Data from 1998 demonstrated a similar spectrum of injuries but with a mortality of 7.2%.

Conclusion

Road traffic collisions are the greatest cause of morbidity and mortality from injury in Kampala, Uganda. When comparing data from 1998 and 2005, the spectrum of injury remained similar, but mortality decreased from 7.2% to 2.7%.     

Kurs „Lebensrettende Sofortmaßnahmen“

Background

First aid administered by lay persons is an essential element in the care of emergency patients. So far, it has seemed to be the weakest link in the “chain of rescue”, meaning that this chain is no stronger than the first aid given. Better first aid would lead to decisively shorter times without treatment.

Methods

At the end of a standard “life-saving first aid” course for lay persons, which is required before candidates can proceed to the German driving test, we used a questionnaire we had developed ourselves to check the theoretical knowledge of the course members .

Results

Most of the participant passed the test of theoretical knowledge held directly after the course. We found no relevant differences between course members who knew about the test at the beginning of the course and those who were not informed about it until the end of the course. Significantly better test results were achieved by persons who had already taken the course several times in the past.

Discussion

We were able to show that repeating first aid courses can improve lay persons’ results in the test of theoretical knowledge at the end of a first aid course. Candidates who also had experience of applying first aid in an emergency also attained significantly better test results.     

Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South Africa

Introduction

Lack of universal, annual testing for human immunodeficiency virus (HIV) in health facilities suggests that expansion of HIV testing and counselling (HTC) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. Consideration should be given to the ability of lay counsellors to perform home-based HTC in community settings.

Methods

We implemented a community cluster randomized controlled trial of home-based HTC in Sisonke District, South Africa. Trained lay counsellors conducted door-to-door HIV testing using the same rapid tests used by the local health department at the time of the study (SD Bioline and Sensa). To monitor testing quality and counsellor skill, additional dry blood spots were taken and sent for laboratory-based enzyme-linked immunosorbent assay (ELISA) testing. Sensitivity and specificity were calculated using the laboratory result as the gold standard.

Results and discussion

From 3986 samples, the counsellor and laboratory results matched in all but 23 cases. In 18 cases, the counsellor judged the result as indeterminate, whereas the laboratory judged 10 positive, eight negative and three indeterminate, indicating that the counsellor may have erred on the side of caution. Sensitivity was 98.0% (95% CI: 96.3–98.9%), and specificity 99.6% (95% CI: 99.4–99.7%), for the lay counsellor field-based rapid tests. Both measures are high, and the lower confidence bound for specificity meets the international standard for assessing HIV rapid tests.

Conclusions

These findings indicate that adequately trained lay counsellors are capable of safely conducting high-quality rapid HIV tests and interpreting the results as per the kit guidelines. These findings are important given the likely expansion of community and home-based testing models and the shortage of clinically trained professional staff.     

Population prevalence of antiretroviral therapy sharing and its association with HIV viremia in rural Uganda: a cross-sectional population-based study

Introduction

Antiretroviral treatment (ART) sharing has been reported among fishermen and sex workers in Uganda and South Africa. However, no population-based studies have documented ART diversion prevalence (including sharing [giving/receiving], buying and selling) or its relationship with viremia among men and women living with HIV in Africa.

Methods

In 2018–2020, we surveyed people living with HIV aged 15–49 years in 41 communities in the Rakai Community Cohort Study, a population-based cohort in south-central Uganda. We assessed the prevalence and correlates of self-reported lifetime and past-year ART diversion, stratifying by age and gender and documenting sources of diverted drugs. We used log-binomial regression to quantify the relationship between diversion patterns and viremia (viral load >40 copies/ml), reported as unadjusted and adjusted prevalence ratios (aPR) with 95% confidence intervals (CI).

Results

Of 2852 people living with HIV and self-reporting current ART use, 266 (9.3%) reported lifetime ART diversion. Giving/receiving drugs were most common; few participants reported buying, and none reported selling. Men (12.9%) were more likely to report lifetime diversion than women (7.4%), with men aged 25–34 reporting high levels of sharing (18.9%). Friends were the most common sources of shared drugs, followed by spouses/sexual partners. Patterns of lifetime and past-year diversion were similar. Among participants with viral load results, 8.6% were viraemic. In adjusted analyses, people who reported only giving ART were nearly twice as likely to be viraemic than those who reported no diversion (aPR: 1.94, 95% CI: 1.10−3.44), and those reporting only receiving ART were less likely to exhibit viremia (aPR: 0.46, 95% CI: 0.12−1.79), although the latter was not statistically significant. Reporting both giving and receiving ART was not associated with viremia (aPR: 0.79, 95% CI: 0.43−1.46). Reporting buying ART, though rare, was also correlated with higher rates of viremia, but this relationship was not statistically significant (aPR: 1.98, 95% CI: 0.72−5.45).

Conclusions

ART sharing is common among persons reporting ART use in rural Uganda, particularly among men. Sharing ART was associated with viremia, and receiving ART may facilitate viral suppression. HIV programmes may benefit from considering ART sharing in counselling messages.     

Atemwegssicherung: Nur etwas für Experten?

Background

Endotracheal intubation (ETI) is the accepted gold standard of airway management and requires a high level of practical skills and regular practice. Several studies have shown a high incidence of unrecognized tube misplacement with possible fatal consequences for the patient outcome. Our aim was to find out if lay personnel are able to perform adequate airway management using supraglottic airway devices (SAD) after minimal training.

Methods

After a short practical demonstration lay persons performed airway management on a dummy with three different SADs (LT laryngeal tube, LMA laryngeal mask airway and CT combitube) and medical personnel ran the same setting without getting the practical demonstration. Primary endpoint was the time elapsed until the first sufficient ventilation with each SAD.

Results

The results showed that even lay persons could perform adequate airway management with certain SADs after minimal training. In this study the laryngeal tube (LT) was the fastest placed SAD (median LT 11.3?s, LMA 11.8?s and CT 20.5?s). Furthermore there was a significant training effect during the repeated attempts (p<0.0001 for attempt 1 vs. 2 according to each SAD). There was no statistical significant difference with respect to the use of the LT by lay persons versus medical personnel (p<0.43 and p<0.08, respectively).

Conclusions

Correct placement of certain SADs can be successfully performed even after minimal training but decision-making concerning indications, treatment of complications and verifying the correct SAD position to secure sufficient ventilation and oxygenation requires expert knowledge and skills. Further studies in the prehospital setting should follow to investigate if SADs are superior to ETI with respect to successful placement.     

Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital,Uganda

Background/purpose

Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition.

Bed net related burns at Mulago National Referral Hospital,Uganda: A case series report

Background

Insecticide-treated bed nets are essential tools to prevent malaria in endemic regions, however, increasing trends in bed net related burns in Kampala, Uganda are concerning.

Methods

Data were collected from burns unit admission records at Mulago National Referral Hospital in Kampala, Uganda for the years 2008–2011 inclusive. Retrospective analyses on the characteristics of patients admitted with bed net related burns within this period were conducted.

Results

A total of 45 patients were admitted to the burns unit with bed net related burns during the study period. Most burns occurred among individuals who were 0–1 years old (33.3%) and 26–35 years old (24.2%) and the majority were male (71%). Bed net related burns at Mulago Hospital are severe, as evidenced by the fact that 15 of 45 patients died (crude mortality rate = 33%) and that 26 patients (57.8%) had total body surface area burn percentages that were greater than 20%. The average length of stay in hospital for patients with bed net related burns was 30.4 days.

Conclusion

Organizations responsible for malaria prevention should consider incorporating fire and burn prevention awareness, strategies and training into their bed net distribution programs.     

Could you have said no? A mixed‐methods investigation of consent to HIV tests in four African countries

Introduction

Although most studies report high frequencies of consent to HIV tests, critics argue that clients are subject to pressure, that acceptors later indicate they could not have refused, and that provider-initiated HIV testing raises serious ethical issues. We examine the meaning of consent and why clients think they could not have refused.

Methods

Clients in Burkina Faso, Kenya, Malawi and Uganda were asked about consenting to HIV tests, whether they thought they could have refused and why. Textual responses were analyzed using qualitative and statistical methods.

Results

Among 926 respondents, 77% reported they could not have said no, but in fact, 60% actively consented to test, 24% had no objection and only 7% tested without consent. There were few significant associations between categories of consent and their covariates.

Conclusions

Retrospectively asking clients if they could have refused to test for HIV overestimates coercion. Triangulating qualitative and quantitative data suggests a considerable degree of agency.