A qualitative assessment of stakeholder perspectives on barriers and facilitators to emergency care delays in Northern Tanzania through the Three Delays

Introduction: Emergency conditions cause a significant burden of death and disability, particularly in developing countries. Prehospital and Emergency Medical Services (EMS) are largely nonexistent throughout Tanzania and little is known about the community's barriers to accessing emergency care. The objective of this study was to better understand local community stakeholder perspectives on barriers, facilitators, and potential solutions surrounding emergency care in the Kilimanjaro region through the Three Delays Model framework. Methods: A qualitative assessment of local stakeholders was conducted through semi-structured focus group discussions (FGDs) from February to June 2021 with five separate groups: hospital administrators, emergency hospital workers, police personnel, fire brigade personnel, and community health workers. FGDs were conducted in Kiswahili, audio recorded, and translated to English verbatim. Two research analysts separately coded the first two FGDs using both inductive and deductive thematic analysis. A final codebook was then created to analyze the remaining FGDs. Results: A total of 24 participants were interviewed. Thematic analysis revealed that participants identified significant barriers within the Three Delays Model as well as identified an additional delay centered on community members and first aid provision. Perceived delays in the decision to seek care, the first delay, were financial constraints and the lack of community education on emergency conditions. Limited infrastructure and reduced transportation access were thought to contribute to the second delay. Potential barriers to receiving timely appropriate care, the third delay, included upfront payments required by hospitals and emergency department intake delays. Suggested solutions focused on increasing education and improving communication and infrastructure. Conclusion: The findings outline barriers to accessing emergency care from a stakeholder perspective. These themes can support recommendations for further strengthening of the prehospital and emergency care system. Due to logistical constraints, emergency care workers interviewed were all from one hospital and patients were not included

Prevention of childhood unintentional injuries in low- and middle-income countries: A systematic review.

Injuries are a leading cause of death and disability among children. Numerous injury prevention strategies have been successful in high-income countries, but the majority of unintentional injuries happen to children living in low- and middle-income countries (LMICs). This project aims to delineate the childhood injury prevention initiatives in LMICs. For inclusion, peer-reviewed articles needed to address unintentional injury, include children <18, assess a prevention-related intervention, contain a control group, and be published after 1988. Two pairs of reviewers evaluated articles independently to determine study eligibility. 74 articles were included. 30 studies addressed road traffic injuries, 11 drowning, 8 burns, 3 falls, 8 poisonings, and 21 an unspecified injury type. The findings show positive effects on injury outcome measures following educational interventions, the need for longer follow-up periods after the intervention, the need for effectiveness trials for behavior change, and the need for an increase in injury prevention services in LMICs. This is the first systematic review to summarize the prevention initiatives for all types of childhood unintentional injuries in LMICs. Increased attention and funding are required to go beyond educational initiatives with self-reported measures and little follow-up time to robust interventions that will reduce the global burden of unintentional injuries among children

Cross-Cultural Adaptation and Psychometric Properties of the SF-8 Questionnaire in Tanzanian Swahili for Injury Population

Background: There is a lack of tools to screen for health-related quality of life (HRQoL) in acute injury patients, despite the critical need for having a good understanding of the characteristics of mental health during the rehabilitation process. The SF-8 instrument, a shorter version of the SF-36, is the most widely used patient-based assessment of HRQoL. The aim of this research is to adapt the psychometric properties of the SF-8 to Swahili. Methods: This study is a secondary data analysis of previously collected and psychometric evaluation of the culturally adapted and translated SF-8. A cross-cultural adaptation committee carried out the process of translation to provide validity evidence based on test content. Confirmatory factor analysis was used to test the internal structure-based evidence. The validity based on relation to other variables (discriminant evidence) was tested using polychoric correlation with PHQ-2 (Patient Health Questionnaire-2). The reliability was tested using Cronbach&rsquo;s alpha, Omega McDonald, and Composite Reliability. Results: 1434 adults who suffered an acute injury and presented to the emergency department between April 2018 and August 2020 were included in the study. The instrument demonstrated language clarity and domain coherence, showing validity evidence based on test content. The CFA (Confirmatory Factor Analysis) analysis showed good fit indices for both models (one- and two-factor models) of the SF-8. The discriminant evidence showed that SF-8 scores correlate strongly with the PHQ-2 instrument. These results supported the validity evidence in relation to other variables. All analyses of reliability were considered adequate with values above 0.90 for both models of the SF-8. Conclusions: The results show that the SF-8 instrument can provide relevant information about the health-related quality of life of acute injury patients, and allow practitioners to gain a better understanding of mental health, improving the treatment and follow-up of injury patients within Tanzanian culture

“I Don’t Do Anything; I’m Just Being Taken Care Of”: Experiences of Patients and Their Caregivers Transitioning Back into the Community Following Traumatic Injury in Northern Tanzania

After discharge from the hospital for traumatic injury, patients and their caregivers face a period of increased vulnerability. This adjustment phase is poorly characterized, especially in low- and middle-income countries. We explored the experiences of patients and their caregivers in Northern Tanzania after hospitalization for a traumatic injury. Patients who received care for traumatic injury at the Kilimanjaro Christian Medical Center and their caregivers were selected as part of a convenience sample from January 2019 to December 2019. Analysts developed a codebook; content and analytic memos were subsequently created. We then applied the biopsychosocial model to further characterize our findings. Participants included 26 patients and 11 caregivers. Patients were mostly middle-aged (mean age 37.7) males (80.8%), residing in urban settings (57.7%), injured in road traffic accidents (65.4%), and who required surgery (69.2%). Most caregivers were female. Seven major themes arose: pain, decreased physical functioning, poor emotional health, lack of support, challenges with daily activities, financial strain, and obstacles to accessing healthcare. This study describes some of the difficulties transitioning back into the community after hospitalization for traumatic injury. Our work demonstrates the importance of mixed methods approaches in characterizing and addressing transitions of care challenges

Using the ADAPT guidance to culturally adapt a brief intervention to reduce alcohol use among injury patients in Tanzania

Background Harmful alcohol use is a leading risk factor for injury-related death and disability in low- and middle-income countries (LMICs). Brief negotiational interventions (BNIs) administered in emergency departments (EDs) to injury patients with alcohol use disorders (AUDs) are effective in reducing post-hospital alcohol intake and re-injury rates. However, most BNIs to date have been developed and implemented in high-income countries. The effectiveness of BNIs in LMICs is largely unknown as few studies have undertaken the rigorous task of culturally adapting these interventions to new settings. Given the high prevalence of alcohol-related injury in the Kilimanjaro region of Tanzania, we culturally adapted a BNI to reduce post-injury alcohol use for implementation in this patient population. Methods Following the ADAPT guidance, we used an iterative, multiphase process to culturally adapt a high-income country BNI to the Tanzanian context. Our team consisted of local healthcare professionals with vast experience in counseling patients and an international team of academic and clinical professionals to integrate our extensive mixed-methods patient data to adapt this intervention. Design group discussions were used to discuss research results, interpret findings, discuss the goals of the intervention, and identify and suggest areas of adaptation of the intervention as well as specific adaptations to the BNI protocol. Objective assessments of our BNI protocol as well as a BNI assessment scale was developed to guide intervention fidelity. Results We developed the Punguza Pombe Kwa Afya Yako (PPKAY); a one-time, 15-minute nurse-led BNI that encourages safe alcohol use and motivates change in alcohol use behaviors among injury patients in the Kilimanjaro region of Tanzania. Adaptations to the original intervention protocol include changes regarding the interventionist, how a patient is greeted, how the topic of alcohol use is raised, how a patient is informed of their harmful alcohol use, how graphics are visualized within the intervention protocol, how behavior change is motivated, and which behavior changes are encouraged. Similarly, we developed a BNI assessment scale to accompany the PPKAY which evaluates adherence to the protocol and motivational interviewing tenants. Conclusions The PPKAY intervention is the first alcohol BNI which was culturally adapted for delivery to injury patients in an African ED. Our study demonstrates our approach to adapting substance use interventions for use in low resource settings and shows that cultural adaptation of alcohol use interventions is feasible, beneficial and empowering for our team. Our study lays a framework and method for other low resourced settings to integrate cultural adaptation into the implementation of a BNI in low resource EDs

HIV Prevalence among Injury Patients Compared to Other High-Risk Groups in Tanzania

Sixty-eight percent of persons infected with HIV live in Africa, but as few as 67% of those know their infection status. The emergency department (ED) might be a critical access point to HIV testing. This study sought to measure and compare HIV prevalence in an ED injury population with other clinical and nonclinical populations across Tanzania. Adults (&ge;18 years) presenting to Kilimanjaro Christian Medical Center ED with acute injury of any severity were enrolled in a trauma registry. A systematic review and meta-analysis was conducted to compare HIV prevalence in the trauma registry with other population groups. Further, 759 injury patients were enrolled in the registry; 78.6% were men and 68.2% consented to HIV counseling and testing. The HIV prevalence was 5.02% (tested), 6.25% (self-report), and 5.31% (both). The systematic review identified 79 eligible studies reporting HIV prevalence (tested) in 33 clinical and 12 nonclinical population groups. Notable groups included ED injury patients (3.53%, 95% CI), multiple injury patients (10.67%, 95% CI), and people who inject drugs (17.43%, 95% CI). These findings suggest that ED injury patients might be at higher HIV risk compared to the general population, and the ED is a potential avenue to increasing HIV testing among young adults, particularly men

Perspectives of COVID‐19 vaccine–hesitant emergency department patients to inform messaging platforms to promote vaccine uptake

ObjectivesEfforts to promote COVID-19 vaccine acceptance must consider the critical role of the emergency department (ED) in providing health care to underserved patients. Focusing on patients who lacked primary care, we sought to elicit the perspectives of unvaccinated ED patients regarding COVID-19 vaccination concerns and potential approaches that might increase their vaccine acceptance.MethodsWe conducted this qualitative interview study from August to November 2021 at four urban EDs in San Francisco, California; Seattle, Washington; Durham, North Carolina; and Philadelphia, Pennsylvania. We included ED patients who were ≥18 years old, fluent in English or Spanish, had not received a COVID-19 vaccine, and did not have primary care physicians or clinics. We excluded patients who were unable to complete an interview, in police custody, under suspicion of active COVID-19 illness, or presented with a psychiatric chief complaint. We enrolled until we reached thematic saturation in relevant domains. We analyzed interview transcripts with a content analysis approach focused on identifying concerns about COVID-19 vaccines and ideas regarding the promotion of vaccine acceptance and potential trusted messengers.ResultsOf 65 patients enrolled, 28 (43%) identified as female, their median age was 36 years (interquartile range 29-49), and 12 (18%) interviews were conducted in Spanish. Primary concerns about COVID-19 vaccines included risk of complications, known and unknown side effects, and fear of contracting COVID-19 from vaccines. Trust played a major role for patients in deciding which sources to use for vaccine information and in engendering vaccine acceptance. Health care providers and family or friends were commonly cited as trusted messengers of information.ConclusionsWe characterized concerns about COVID-19 vaccines, uncovered themes that may promote vaccine acceptance, and identified trusted messengers-primarily health care professionals. These data may inform the development of nuanced COVID-19 vaccine messaging platforms to address COVID-19 vaccine hesitancy among underserved ED populations

HIV Prevalence among Injury Patients Compared to Other High-Risk Groups in Tanzania

Sixty-eight percent of persons infected with HIV live in Africa, but as few as 67% of those know their infection status. The emergency department (ED) might be a critical access point to HIV testing. This study sought to measure and compare HIV prevalence in an ED injury population with other clinical and nonclinical populations across Tanzania. Adults (≥18 years) presenting to Kilimanjaro Christian Medical Center ED with acute injury of any severity were enrolled in a trauma registry. A systematic review and meta-analysis was conducted to compare HIV prevalence in the trauma registry with other population groups. Further, 759 injury patients were enrolled in the registry; 78.6% were men and 68.2% consented to HIV counseling and testing. The HIV prevalence was 5.02% (tested), 6.25% (self-report), and 5.31% (both). The systematic review identified 79 eligible studies reporting HIV prevalence (tested) in 33 clinical and 12 nonclinical population groups. Notable groups included ED injury patients (3.53%, 95% CI), multiple injury patients (10.67%, 95% CI), and people who inject drugs (17.43%, 95% CI). These findings suggest that ED injury patients might be at higher HIV risk compared to the general population, and the ED is a potential avenue to increasing HIV testing among young adults, particularly men