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Introduction: Pediatric injuries in low- and middle-income countries are a leading cause of morbidity and mortality worldwide. Implementing hospital-based trauma registries can reduce the knowledge gap in both hospital care and patient outcomes and lead to quality improvement initiatives. The goal of this study was to create a pediatric trauma registry to provide insight into the epidemiology, outcomes, and factors associated with poor outcomes in injured children., Methods: This was a prospective observational study in which a pediatric trauma registry was implemented at a large zonal referral hospital in Northern Tanzania. Data included demographics, hospital-based care, and outcomes including morbidity and mortality. Data were input into REDCap© and analyzed using ANOVA and Chi-squared tests in SAS(Version 9.4)©., Results: 365 patients were enrolled in the registry from November 2020 to October 2021. The majority were males (n=240, 65.8%). Most were children 0-5 years (41.7%, n=152), 34.5% (n=126) were 6-11 years, and 23.8% (n=87) were 12-17 years. The leading causes of pediatric injuries were falls (n=137, 37.5%) and road traffic injuries (n=125, 34.5%). The mortality rate was 8.2% ( n=30 ). Of the in-hospital deaths, 43.3% were children with burn injuries who also had a higher odds of mortality than children with other injuries (OR 8.72, p <0.001). The factors associated with in-hospital mortality and morbidity were vital sign abnormalities, burn severity, abnormal Glasgow Coma Score, and ICU admission., Conclusion: The mortality rate of injured children in our cohort was high, especially in children with burn injuries. In order to reduce morbidity and mortality, interventions should be prioritized that focus on pediatric injured patients that present with abnormal vital signs, altered mental status, and severe burns. These findings highlight the need for health system capacity building to improve outcomes of pediatric injury patients in Northern Tanzania., Competing Interests: The authors declared no conflicts of interest., (© 2022 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Objective: Myriad reasons, including stigma, may prevent patients from self-reporting harmful use of alcohol in Tanzania. Family members may be more forthright but might not know the extent of the patient's alcohol use or suffer alcohol-related stigma as well. Our study aims to compare the reporting of patient alcohol use by emergency department patients themselves and their family members in Tanzania in order to describe the potential use of family reports as a proxy for patient self-reports., Method: We conducted a secondary descriptive analysis of a prospective cohort of adult patients seeking treatment for injury and their family members. We evaluated alcohol use behavior, alcohol-related consequences, and alcohol-related stigma reported by 231 patients and 231 family members (both majority male, ages 25-45 years), measured by the Alcohol Use Disorders Identification Test (AUDIT), Perceived Alcohol Stigma (PAS) scale, and the Drinker Inventory of Consequences (DrInC). Alcohol use behavior concordance/discordance between patients and families was established, and alcohol use and perceived stigma were analyzed., Results: More than 72% of patient-family pairs showed alcohol use (AUDIT) concordance. Receiver operating characteristic curve and regression analysis suggests family reports to be clinically relevant, significant, and potentially accurate markers of patient alcohol use (sensitivity: 95.10%, specificity: 69.77%). Findings support the existence of stigma toward alcohol in this context, with similar stigma levels of patients and family members., Conclusions: Family-reported patient alcohol use may be an accurate proxy for patient self-reporting. Further research is needed into stigma toward alcohol that is culturally appropriate and adopted.

Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Keating et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

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., Competing Interests: Conflicts of Interest: The authors declare no conflict of interest.

Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.

Background: Significant disparities exist for timely access to cancer care for children, with the highest disparities in low- and middle-income countries (LMICs). This study aims to conduct a systematic review that identifies the factors contributing to delayed care of childhood cancers in LMICs., Methods: We will conduct a systematic review with search strings compliant with the PICO framework: (1) the Population-children (aged 0-18 years) from LMICs; (2) the Exposure-factors contributing to timely childhood cancer care; (3) the Outcome-delays in childhood cancer care., Discussion: Our study is an essential step to guide strategic interventions to assess the myriad of factors that prevent children from accessing timely cancer care in LMICs. The results will be submitted for publication in a peer-reviewed journal and shared with institutions related to the field., (© 2022 Wiley Periodicals LLC.)

Background: Disease and disability from alcohol use disproportionately impact people in low- and middle-income countries (LMICs). While varied interventions have been shown to reduce alcohol use in high-income countries, their efficacy in LMICs has not been assessed. This systematic review describes current published literature on patient-level alcohol interventions in LMICs and specifically describes clinical trials evaluating interventions to reduce alcohol use in LMICs., Methods and Findings: In accordance with PRISMA, we performed a systematic review using an electronic search strategy from January 1, 1995 to December 1, 2020. Title, abstract, as well as full-text screening and extraction were performed in duplicate. A meta-summary was performed on randomized controlled trials (RCTs) that evaluated alcohol-related outcomes. We searched the following electronic databases: PubMed, EMBASE, Scopus, Web of Science, Cochrane, WHO Global Health Library, and PsycINFO. Articles that evaluated patient-level interventions targeting alcohol use and alcohol-related harm in LMICs were eligible for inclusion. No studies were excluded based on language. After screening 5,036 articles, 117 articles fit our inclusion criteria, 75 of which were RCTs. Of these RCTs, 93% were performed in 13 middle-income countries, while 7% were from 2 low-income countries. These RCTs evaluated brief interventions (24, defined as any intervention ranging from advice to counseling, lasting less than 1 hour per session up to 4 sessions), psychotherapy or counseling (15, defined as an interaction with a counselor longer than a brief intervention or that included a psychotherapeutic component), health promotion and education (20, defined as an intervention encouraged individuals' agency of taking care of their health), or biologic treatments (19, defined as interventions where the biological function of alcohol use disorder (AUD) as the main nexus of intervention) with 3 mixing categories of intervention types. Due to high heterogeneity of intervention types, outcome measures, and follow-up times, we did not conduct meta-analysis to compare and contrast studies, but created a meta-summary of all 75 RCT studies. The most commonly evaluated intervention with the most consistent positive effect was a brief intervention; similarly, motivational interviewing (MI) techniques were most commonly utilized among the diverse array of interventions evaluated., Conclusions: Our review demonstrated numerous patient-level interventions that have the potential to be effective in LMICs, but further research to standardize interventions, populations, and outcome measures is necessary to accurately assess their effectiveness. Brief interventions and MI techniques were the most commonly evaluated and had the most consistent positive effect on alcohol-related outcomes., Trial Registration: Protocol Registry: PROSPERO CRD42017055549., Competing Interests: The authors have declared that no competing interests exist.

Background: Alcohol use in resource-limited settings results in significant morbidity and mortality. These settings lack the necessary specialty-trained personnel and infrastructure. Therefore, implementing evidence-based interventions from high-income settings, like a brief negotiational intervention (BNI) for alcohol, will require rapid production of evidence of effectiveness to guide implementation priorities. Thus, this study describes a clinical trial protocol to rapidly optimize and evaluate the impact of a culturally adapted BNI to reduce alcohol-related harms and alcohol consumption among injury patients., Methods: Our pragmatic, adaptive, randomized controlled trial (PRACT) is designed to determine the most effective intervention approach to reduce hazardous alcohol use among adult (≥18 years old) in acute (< 24 h) injury patients. Our culturally adapted, nurse-delivered, intervention (PPKAY) has been augmented with evidence-based, culturally appropriate standards and will be evaluated as follows. Stage 1 of the trial will determine if PPKAY, either with a standard short-message-service (SMS) booster or with a personalized SMS booster is more effective than usual care (UC). While optimizing statistical efficiency, Stage 2 drops the UC arm to compare the PPKAY with a standard SMS booster to PPKAY with a personalized SMS booster. Finally, in Stage 3, the more effective arm in Stage 2 is compared to PPKAY without an SMS booster. The study population is acute injury patients who present to Kilimanjaro Christian Medical Centre, Tanzania, who (1) test alcohol positive by breathalyzer upon arrival; (2) have an Alcohol Use Disorder Identification Test of 8 or above; and/or (3) have reported drinking alcohol prior to their injury. Outcome measures will be evaluated for all arms at 3, 6, 9, 12, and 24 months. The primary outcome for the study is the reduction of the number of binge drinking days in the 4 weeks prior to follow-up. Secondary outcomes include alcohol-related consequences, measured by the Drinker Inventory of Consequences., Discussion: The findings from this study will be critically important to identify alcohol harm reduction strategies where alcohol research and interventions are scarce. Our innovative and adaptive trial design can transform behavior change research and identify the most effective nurse-driven intervention to be targeted for integration into standard care., Trial Registration: ClinicalTrials.gov NCT04535011 . Registered on September 1, 2020., (© 2022. The Author(s).)

Background: To improve healthcare access and mitigate healthcare costs for its population, Nigeria established a National Health Insurance Scheme (NHIS) in 1999. The NHIS remains Nigeria's leading vehicle for achieving universal health coverage; nonetheless, questions remain regarding its quality and effectiveness. Studies on patient satisfaction have served as a useful strategy to further understand the patient experience and the efficacy of health systems., Aim: To synthesise current knowledge on patient satisfaction with the NHIS., Methods: The authors performed a systematic review of primary literature from 1999 to 2020 reporting on NHIS patient satisfaction in eight databases (including PubMed, Embase, and Africa-wide Information)., Results: This search returned 764 unique records of which 21 met criteria for full data extraction. The 21 qualifying studies representing 11 of the 36 Nigerian states, were published from 2011 to 2020, and found moderate overall satisfaction with the NHIS (64%). Further, when disaggregated into specific domains, NHIS enrolees were most satisfied with provider attitudes (77%) and healthcare environments (70%), but less satisfied with laboratories (62%), billings (62%), pharmaceutical services (56%), wait times (55%), and referrals (51%). Importantly, time trends indicate satisfaction with the NHIS is increasing - although to differing degrees depending on the domain., Conclusion: The beneficiaries of the NHIS are moderately satisfied with the scheme. They consider it an improvement from being uninsured, but believe that the scheme can be considerably improved. The authors present two main recommendations: (1) shorter wait times may increase patient satisfaction and can be a central focus in improving the overall scheme, and (2) more research is needed across all 36 states to comprehensively understand patient satisfaction towards NHIS in anticipation of potential scheme expansion.

Background: The new coronavirus disease (COVID-19) has claimed thousands of lives worldwide and disrupted the health system in many countries. As the national emergency care capacity is a crucial part of the COVID-19 response, we evaluated the Brazilian Health Care System response preparedness against the COVID-19 pandemic. Methods: A retrospective and ecological study was performed with data retrieved from the Brazilian Information Technology Department of the Public Health Care System. The numbers of intensive care (ICU) and hospital beds, general or intensivist physicians, nurses, nursing technicians, physiotherapists, and ventilators from each health region were extracted. Beds per health professionals and ventilators per population rates were assessed. A health service accessibility index was created using a two-step floating catchment area (2SFCA). A spatial analysis using Getis-Ord Gi * was performed to identify areas lacking access to high-complexity centers (HCC). Results: As of February 2020, Brazil had 35,682 ICU beds, 426,388 hospital beds, and 65,411 ventilators. In addition, 17,240 new ICU beds were created in June 2020. The South and Southeast regions have the highest rates of professionals and infrastructure to attend patients with COVID-19 compared with the northern region. The north region has the lowest accessibility to ICUs. Conclusions: The Brazilian Health Care System is unevenly distributed across the country. The inequitable distribution of health facilities, equipment, and human resources led to inadequate preparedness to manage the COVID-19 pandemic. In addition, the ineffectiveness of public measures of the municipal and federal administrations aggravated the pandemic in Brazil., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Silva, Carvalho Dutra, Andrade, Iora, Rodrigues Ramajo, Peres Gualda, Costa Scheidt, Vasconcelos Maia do Amaral, Hernandes Rocha, Staton, Nickenig Vissoci and Fressatti Cardoso.)

Traumatic injuries afflict more than 5 million people globally every year. Current and past animal research has demonstrated association among alcohol, trauma, and impaired immune function, whereas human registries have shown association between alcohol and morbidity as well as mortality. The purpose of this study is to elucidate the immune interactions with alcohol in traumatically injured patients. We prospectively enrolled 379 patients after trauma at three medical centers in the Surgical Critical Care Initiative. Plasma was analyzed using Luminex for up to 35 different cytokines. Collected samples were grouped by patients with detectable plasma alcohol levels versus those without. Univariate testing determined differences in analytes between groups. We built Bayesian belief networks with multiple minimum descriptive lengths to compare the two groups. All 379 patient samples were analyzed. Two hundred eighty-two (74.4%) patients were men, and 143 (37.7%) were White. Patients had a median intensive care unit length of stay (LOS) of 5.8 days and hospital LOS of 12 days. Using single variate analyses, eight different cytokines were differentially associated with alcohol. Cytokines IL-12 and IL-6 were important nodes in both models and IL-10 was a prominent node in the nonalcohol model. This study found select immune function differed between traumatically injured patients with measurable serum alcohol levels as compared with those without. Traumatically injured patients with positive blood alcohol content appear less able to inhibit inflammatory stress. Alcohol appears to suppress pro-inflammatory IL-12 and IL-6, whereas patients without alcohol have greater levels of anti-inflammatory IL-10 expressed at injury and may better regulate anti-inflammatory pathways. Future studies should determine the relationship with these markers with clinically oriented outcomes., (© 2021 The Authors. Clinical and Translational Science published by Wiley Periodicals LLC on behalf of the American Society for Clinical Pharmacology and Therapeutics.)

As machine learning (ML) and precision medicine become more readily available and used in practice, emergency physicians must understand the potential advantages and limitations of the technology. This narrative review focuses on the key components of machine learning, artificial intelligence, and precision medicine in emergency medicine (EM). Based on the content expertise, we identified articles from EM literature. The authors provided a narrative summary of each piece of literature. Next, the authors provided an introduction of the concepts of ML, artificial intelligence as an extension of ML, and precision medicine. This was followed by concrete examples of their applications in practice and research. Subsequently, we shared our thoughts on how to consume the existing research in these subjects and conduct high-quality research for academic emergency medicine. We foresee that the EM community will continue to adapt machine learning, artificial intelligence, and precision medicine in research and practice. We described several key components using our expertise., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Lee et al.)

Background: Injuries account for about 13% of all registered deaths in Sri Lanka and are the leading cause of admission to public hospitals. Prehospital trauma care is new to Sri Lanka, and in 2016, a free ambulance service was launched in the Western and Southern provinces., Objective: The aim of this study was to identify the proportion of admitted injury patients at a tertiary hospital who used an ambulance to get to the first health facility and examine patient demographics, injury event, and injury type as predictors of ambulance transport., Methods: A cross-sectional survey was administered to 405 patients who were admitted to the emergency trauma center at Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. Descriptive statistics were tabulated to summarize prehospital transportation variables. Logistic regression models were created to examine predictors of ambulance transport, and ArcGIS Pro was used to calculate the distance between injury location and first facility and THK., Results: The proportion of patients with injuries who used an ambulance to get to the first health facility was 20.5%. Factors that were significantly associated with ambulance use were older age, injury mechanism, alcohol use prior to injury, location type, open wound, abrasion, and chest/abdomen injury. Distance from injury location to THK or nearest health facility were not significantly associated with ambulance transport to the first health facility., Conclusion: Among lower acuity injury patients in southern Sri Lanka, 20.5% traveled in an ambulance to the first health facility, while over half used a tuk tuk. Older age and injuries at home were associated with lower odds of ambulance transport. Future studies on predictors of ambulance transport should include patients with more severe injuries, gather detailed data on care provided while in transport and examine the association between prehospital care and clinical outcomes., Competing Interests: The authors have declared that no competing interests exist.

Objective: Compared indicators of potential access to oral health services sought in two cycles of the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB), verifying whether the program generated changes in access to oral health services., Methods: Transitional analysis of latent classes was used to analyze two cross-sections of the external evaluation of the PMAQ-AB (Cycle I: 2011-2012 and Cycle II: 2013-2014), identifying completeness classes for a structure and work process related to oral health. Consider three indicators of structure (presence of a dental surgeon, existence of a dental office and operating at minimum hours) and five of the work process (scheduling every day of the week, home visits, basic dental procedures, scheduling for spontaneous demand and continuation of treatment). Choropleth maps and hotspots were made., Results: The proportion of elements that had one or more dentist (CD), dental office and operated at minimum hours varied from 65.56% to 67.13 between the two cycles of the PMAQ-AB. The number of teams that made appointments every day of the week increased 8.7% and those that made home visits varied from 44.51% to 52.88%. The reduction in the number of teams that reported guaranteeing the agenda for accommodating spontaneous demand, varying from 62.41% to 60.11% and in the continuity of treatment, varying from 63.41% to 61.11%. For the structure of health requirements, the predominant completeness profile was "Best completeness" in both cycles, comprising 71.0% of the sets at time 1 and 67.0% at time 2. The proportion of teams with "Best completeness" increased by 89.1%, the one with "Worst completeness" increased by 20%, while those with "Average completeness" decreased by 66.3%., Conclusion: We identified positive changes in the indicators of potential access to oral health services, expanding the users' ability to use them. However, some access attributes remain unsatisfactory, with organizational barriers persisting., Competing Interests: The authors have declared that no competing interests exist.

Global suicide rates have increased in recent decades becoming a serious social and public health problem. In Brazil, rates have been increasing annually. We aimed to analyze the correlation between suicide mortality rates and global economic and political crisis periods of 2008 and 2014 in Brazil. The analysis of suicide mortality in Brazil was done using a time-series segmented linear regression model that estimated the trend of rates over time. To obtain the model, changes in the trend of both abrupt and gradual suicide rates were investigated. The results indicate statistically significant changes showing an upward trend of suicide rates during the world economic crisis (2008-2013) and during the economic and political crisis in Brazil (2014-2017) compared to previous periods, especially at the extremes of schooling (3 < years and > 8 years). Among white and parda, there were significant trend rates increases in both periods and in different regions. In the Northeast and South regions, we observed a significant increase in the trend rate for males after the Brazilian economic and political crisis (2014 to 2017). We can conclude that the national suicide rates were influenced by the economic and political instability that our country has been going through since 2008, affecting each region differently. Further studies are needed to explore the reasons for interregional differences and the relation of suicide with unemployment rates and possible economic predictors., (© 2021 The Author(s).)

Background: No other disease has killed more than ischemic heart disease (IHD) for the past few years globally. Despite the advances in cardiology, the response time for starting treatment still leads patients to death because of the lack of healthcare coverage and access to referral centers., Objectives: To analyze the spatial disparities related to IHD mortality in the Parana state, Brazil., Methods: An ecological study using secondary data from Brazilian Health Informatics Department between 2013-2017 was performed to verify the IHD mortality. An spatial analysis was performed using the Global Moran and Local Indicators of Spatial Association (LISA) to verify the spatial dependency of IHD mortality. Lastly, multivariate spatial regression models were also developed using Ordinary Least Squares and Geographically Weighted Regression (GWR) to identify socioeconomic indicators (aging, income, and illiteracy rates), exam coverage (catheterization, angioplasty, and revascularization rates), and access to health (access index to cardiologists and chemical reperfusion centers) significantly correlated with IHD mortality. The chosen model was based on p < 0.05, highest adjusted R 2 and lowest Akaike Information Criterion., Results: A total of 22,920 individuals died from IHD between 2013-2017. The spatial analysis confirmed a positive spatial autocorrelation global between IDH mortality rates (Moran's I: 0.633, p < 0.01). The LISA analysis identified six high-high pattern clusters composed by 66 municipalities (16.5%). GWR presented the best model (Adjusted R 2 : 0.72) showing that accessibility to cardiologists and chemical reperfusion centers, and revascularization and angioplasty rates differentially affect the IHD mortality rates geographically. Aging and illiteracy rate presented positive correlation with IHD mortality rate, while income ratio presented negative correlation (p < 0.05)., Conclusion: Regions of vulnerability were unveiled by the spatial analysis where sociodemographic, exam coverage and accessibility to health variables impacted differently the IHD mortality rates in Paraná state, Brazil., Highlights: The increase in ischemic heart disease mortality rates is related to geographical disparities.The IHD mortality is differentially associated to socioeconomic factors, exam coverage, and access to health.Higher accessibility to chemical reperfusion centers did not necessarily improve patient outcomes in some regions of the state.Clusters of high mortality rate are placed in regions with low amount of cardiologists, income and schooling., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

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., Competing Interests: The authors have declared that no competing interests exist.

Cardiovascular diseases are the leading cause of deaths globally. Machine learning studies predicting mortality rates for ischemic heart disease (IHD) at the municipal level are very limited. The goal of this paper was to create and validate a Heart Health Care Index (HHCI) to predict risk of IHD based on location and risk factors. Secondary data, geographical information system (GIS) and machine learning were used to validate the HHCI and stratify the IHD municipality risk in the state of Paraná. A positive spatial autocorrelation was found (Moran's I = 0.6472, p-value = 0.001), showing clusters of high IHD mortality. The Support Vector Machine, which had an RMSE of 0.789 and error proportion close to one (0.867), was the best for prediction among eight machine learning algorithms after validation. In the north and northwest regions of the state, HHCI was low and mortality clusters patterns were high. By creating an HHCI through ML, we can predict IHD mortality rate at municipal level, identifying predictive characteristics that impact health conditions of these localities' guided health management decisions for improvements for IHD within the emergency care network in the state of Paraná., Competing Interests: The authors have declared that no competing interests exist.

Background: The Kilimanjaro region has one of the highest levels of reported alcohol intake per capita in Tanzania. Age at first drink has been found to be associated with alcohol problems in adulthood, but there is less information on the age of first drink in the Kilimanjaro region and its associations with alcohol-related consequences later in life. Furthermore, local alcohol cost and availability may influence the prevalence of alcohol use and alcohol use disorders., Methods: Data on the age of first drink, alcohol use disorder identification tool (AUDIT), number and type of alcohol consequences (DrInC), and perceived alcohol at low cost and high availability for children and adolescents were collected from an alcohol and health behavior survey of injury patients (N = 242) in Moshi, Tanzania. Generalized linear models were used to test age at first drink, perceived alcohol cost and availability, and their association with the AUDIT and DrInC scores, and current alcohol use, respectively., Results: Consuming alcohol before age 18 was significantly associated with higher AUDIT and DrInC scores, with odds ratios of 1.22 (CI: 1.004, 1.47) and 1.72 (CI: 1.11, 2.63), respectively. Female gender is strongly associated with less alcohol use and alcohol consequences, represented by an odds ratio of 3.70 (CI: 1.72, 8.33) for an AUDIT score above 8 and an odds ratio of 3.84 (CI: 2.13, 6.67) with the DrInC score. Perceived high availability of alcohol for children is significantly related to higher alcohol use quantity, with the odds ratio of 1.6 (CI: 1.17, 2.20)., Conclusions: The first use of alcohol before the age of 18 is associated with higher alcohol use and alcohol-related adverse consequences. In Tanzania, age at first drink is an important target for interventions aiming to prevent negative alcohol-related consequences later in life., (© 2020 by the Research Society on Alcoholism.)

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., Competing Interests: Declaration of Competing Interest The authors declare that there are no competing interests related to this manuscript., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., Competing Interests: The authors have declared that no competing interests exist.

Objective: The Kilimanjaro region has one of the highest rates of reported alcohol use per capita in Tanzania. Alcohol-related risky behaviors pose substantial threats to the health and well-being of alcohol users and the people around them. This study seeks to understand how alcohol-related risky behaviors co-occur with other risky behaviors., Method: Latent class analysis (LCA) was applied to examine alcohol-related risky behaviors. The optimal number of latent classes was confirmed by using model fit indices. Negative binomial models were used to test latent classes and their association with harmful and hazardous drinking and perceived alcohol stigma. With the model defined, we explored each class's drinking patterns and risky behavior patterns., Results: A total of 622 (60% male) of 841 participants were included in these analyses because they drank alcohol at least once in their lifetime. Three classes of risky behavior patterns were identified: Class 1, "Limited risk behaviors" (59.7%); Class 2, "Primarily foolish behaviors" (25.6%); and Class 3, "Pervasive risk behaviors" (13.1%). Class 3 had the most alcohol use quantity and frequency. No association between classes and alcohol stigma was found. Compared with males, females are less likely to be classified in Class 2 and 3., Conclusions: Three different classes of risky behaviors became apparent and were distinguished by gender, age, and personal alcohol use. Our findings suggest a potential role for personalized interventions based on latent classes specifically to reduce risk behaviors.

Background: Traumatic brain injury (TBI) prognostic models are potential solutions to severe human and technical shortages. Although numerous TBI prognostic models have been developed, none are widely used in clinical practice, largely because of a lack of feasibility research to inform implementation. We previously developed a prognostic model and Web-based application for in-hospital TBI care in low-resource settings. In this study, we tested the feasibility, acceptability, and usability of the application with potential end-users., Methods: We performed our feasibility assessment with providers involved in TBI care at both a regional and national referral hospital in Uganda. We collected qualitative and quantitative data on decision support needs, application ease of use, and implementation design., Results: We completed 25 questionnaires on potential uses of the app and 11 semistructured feasibility interviews. Top-cited uses were informing the decision to operate, informing the decision to send the patient to intensive care, and counseling patients and relatives. Participants affirmed the potential of the application to support difficult triage situations, particularly in the setting of limited access to diagnostics and interventions, but were hesitant to use this technology with end-of-life decisions. Although all participants were satisfied with the application and agreed that it was easy to use, several expressed a need for this technology to be accessible by smartphone and offline., Conclusions: We elucidated several potential uses for our app and important contextual factors that will support future implementation. This investigation helps address an unmet need to determine the feasibility of TBI clinical decision support systems in low-resource settings., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Road traffic injuries (RTI) cause ∼1.2 million deaths and 50 million injuries annually, disproportionately occurring in low- and middle-income countries. Although policy changes and infrastructural developments have continued to contribute to the decrease in RTI-related deaths, limited studies have investigated the relationship between motorcycle taxi driver behaviors and RTIs in Rwanda. This study aims to describe the safety behaviors of commercial motorcyclists in Kigali, Rwanda. Methods: We surveyed 609 commercial motorcyclists in January 2014 then conducted a cross-sectional analysis of the results, including descriptive and bivariate logistic regression analyses. Results: We found that 38.7% of surveyed motorcycle drivers experienced a crash during their lifetime, of which, more than half (n = 134, 56.8%) suffered injuries. Of all injuries, 38.8% (n = 52) resulted in hospitalization, and 14.2% (n = 19) in disability. Among motorcyclists, 100% reported always wearing a helmet, 99% reported always wearing a chin strap, and 98.8% reported always having a passenger helmet. There was an association between sustaining a crash and believing that helmets (p = 0.08) and chin straps (p = 0.05) reduced crash risk. Conclusions: Rwandan commercial motorcyclists demonstrate generally proper safety behaviors, but remain a high-risk occupational group. Road safety policy initiatives have been effective in changing driver behavior regardless of driver safety beliefs.

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., Competing Interests: The authors have declared that no competing interests exist.

Objective: Traumatic brain injury (TBI), a burgeoning global health concern, is one condition that could benefit from prognostic modeling. Risk stratification of TBI patients on presentation to a health facility can support the prudent use of limited resources. The CRASH (Corticosteroid Randomisation After Significant Head Injury) model is a well-established prognostic model developed to augment complex decision-making. The authors' current study objective was to better understand in-hospital decision-making for TBI patients and determine whether data from the CRASH risk calculator influenced provider assessment of prognosis., Methods: The authors performed a choice experiment using a simulated TBI case. All participant doctors received the same case, which included a patient history, vitals, and physical examination findings. Half the participants also received the CRASH risk score. Participants were asked to estimate the patient prognosis and decide the best next treatment step. The authors recruited a convenience sample of 28 doctors involved in TBI care at both a regional and a national referral hospital in Uganda., Results: For the simulated case, the CRASH risk scores for 14-day mortality and an unfavorable outcome at 6 months were 51.4% (95% CI 42.8%, 59.8%) and 89.8% (95% CI 86.0%, 92.6%), respectively. Overall, participants were overoptimistic when estimating the patient prognosis. Risk estimates by doctors provided with the CRASH risk score were closer to that score than estimates made by doctors in the control group; this effect was more pronounced for inexperienced doctors. Surgery was selected as the best next step by 86% of respondents., Conclusions: This study was a novel assessment of a TBI prognostic model's influence on provider estimation of risk in a low-resource setting. Exposure to CRASH risk score data reduced overoptimistic prognostication by doctors, particularly among inexperienced providers.

Objective: To evaluate the association among characteristics of primary health care center (PHCC) with hospitalizations for primary care sensitive conditions (PCSC) in Brazil., Method: In this study, a cross-sectional ecological study was performed. This study analyzed the 27 capitals of Brazil's federative units. Data were aggregated from the following open access databases: National Program for Access and Quality Improvement in Primary Care, the Hospital Information System of Brazilian Unified Health System and Annual Population Census conducted by the Brazilian Institute of Geography and Statistics. Associations were estimated among characteristics of primary care with the number of three PCSC as the leading causes of hospitalization in children under-5 population in Brazil: asthma, diarrhea, and pneumonia., Results: In general, PHCC showed limited structural adequacy (37.3%) for pediatric care in Brazil. The capitals in South and Southeast regions had the best structure whereas the North and Northeast had the worst. Fewer PCSC hospitalizations were significantly associated with PHCC which presented appropriate equipment (RR: 0.98; 95%CI: 0.97-0.99), structural conditions (RR: 0.98; 95%CI: 0.97-0.99), and signage/identification of professionals and facilities (RR: 0.98; 95%CI: 0.97-0.99). Higher PCSC hospitalizations were significantly associated with PHCC with more physicians (RR: 1.23, 95%CI: 1.02-1.48), it forms (RR: 1.01, 95%CI: 1.01-1.02), and more medications (RR: 1.02, 95%CI: 1.01-1.03)., Conclusion: Infrastructural adequacy of PHCC was associated with less PCSC hospitalizations, while availability medical professional and medications were associated with higher PCSC hospitalizations.

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., Competing Interests: Conflicts of interests No conflicts declared., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To conduct a geospatial analysis of suicide deaths among young people in the state of Paraná, southern Brazil, and evaluate their association with socioeconomic and spatial determinants., Methods: Data were obtained from the Mortality Information System and the Brazilian Institute of Geography and Statistics. Data on suicide mortality rates (SMR) were extracted for three age groups (15-19, 20-24, and 25-29 years) from two 5-year periods (1998-2002 and 2008-2012). Geospatial data were analyzed through exploratory spatial data analysis. We applied Bayesian networks algorithms to explore the network structure of the socioeconomic predictors of SMR., Results: We observed spatial dependency in SMR in both periods, revealing geospatial clusters of high SMR. Our results show that socioeconomic deprivation at the municipality level was an important determinant of suicide in the youth population in Paraná, and significantly influenced the formation of high-risk SMR clusters., Conclusion: While youth suicide is multifactorial, there are predictable geospatial and sociodemographic factors associated with high SMR among municipalities in Paraná. Suicide among youth aged 15-29 occurs in geographic clusters which are associated with socioeconomic deprivation. Rural settings with poor infrastructure and development also correlate with increased SMR clusters.

Background: Intimate partner violence is a global health burden that disproportionately affects women and their health outcomes. Women in Brazil are also affected by interpersonal violence. We aimed to estimate the lifetime prevalence of three forms of interpersonal violence against women (IPVAW) and to identify sociodemographic factors associated with IPVAW in one urban Brazilian city., Methods: Using a cross-sectional design, we interviewed women aged ≥18 years in the urban Brazilian city, Maringá, who currently have or have had an intimate partner. The 13-item WHO Violence Against Women instrument was used to ask participants about their experiences with intimate partner violence, categorized into psychological, physical and sexual violence. We estimated associations between IPVAW and sociodemographic characteristics using generalized linear models., Results and Conclusions: Of the 419 women who were enrolled and met inclusion criteria, lifetime prevalence of IPVAW was 56%. Psychological violence was more prevalent (52%) than physical (21%) or sexual violence (13%). Twenty-eight women (6.4%) experienced all three forms of IPVAW. Women were more likely to experience violence if they were employed, did not live with their partner or had 4 or more children. Educational level, household income, age and race were not significantly associated factors. Our findings highlight a high prevalence of IPVAW in a community in southern Brazil., Competing Interests: The authors have declared that no competing interests exist.

Objective: The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury., Methods: The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania., Results: Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI., Conclusions: Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

Introduction: Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa., Methods: A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL., Results: Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic complications, the most common admission diagnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%)., Conclusions: The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hypertension and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hospitalizations highlights the urgent need for improvements in primary preventative care in Tanzania., Competing Interests: Competing Interests: None declared., (Copyright © 2019, Ethnicity & Disease, Inc.)

Objectives: The objective of this study is to increase understanding of knowledge, attitudes, and preventative practices regarding ischemic heart disease (IHD) in sub-Saharan Africa in order to develop patient-centered interventions to improve care and outcomes., Study Design: This is a prospective observational study., Methods: Adult patients presenting with chest pain or shortness of breath to an emergency department in northern Tanzania were enrolled. A questionnaire was adapted from existing knowledge attitude and practice surveys regarding cardiovascular disease and the WHO STEPS instrument. Individual five-year risk of cardiovascular event was determined by validated models based on age, sex, systolic blood pressure, body mass index, diabetes, and smoking status. An IHD knowledge score was calculated by giving one point for each correct response to the knowledge-related items, with a maximum score of 10. Associations between IHD knowledge and patient characteristics were assessed by Welch's t-test., Results: A total of 349 patients were enrolled, with median interquartile range (IQR) age 60 (45, 72) years. Of participants, 259 (74.2%) had hypertension, and 228 (65.3%) had greater than 10% five-year risk of cardiovascular event. The mean (SD) knowledge score was 4.8 (3.3). The majority of respondents (224, 64.2%) recognized obesity as a risk factor for heart attack, while a minority (34, 9.7%) knew that a daily aspirin could reduce the risk of cardiovascular event. Greater IHD knowledge was associated with younger age (P = 0.045) and higher levels of education (P < 0.001) but not higher risk of cardiovascular disease (P = 0.123). Most respondents expressed a willingness to diet to improve their health (322, 92.3%) and a preference for treatment from a physician rather than a traditional healer for a heart attack (321, 92.0%). A minority of patients reported exercising regularly (88, 25.2%) or seeing a doctor routinely for checkups (100, 28.7%)., Conclusions: High-risk emergency department patients in northern Tanzania have moderate knowledge regarding IHD but do not consistently engage in healthy preventive practices. Patient-centered interventions are needed to improve IHD knowledge and practices in high-risk populations., (Copyright © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Objective: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionate burden of this injury on low- and middle-income countries (LMICs). Limited access to diagnostic technologies and highly skilled providers combined with high patient volumes contributes to poor outcomes in LMICs. Prognostic modeling as a clinical decision support tool, in theory, could optimize the use of existing resources and support timely treatment decisions in LMICs. The objective of this study was to develop a machine learning-based prognostic model using data from Kilimanjaro Christian Medical Centre in Moshi, Tanzania., Methods: This study is a secondary analysis of a TBI data registry including 3138 patients. The authors tested nine different machine learning techniques to identify the prognostic model with the greatest area under the receiver operating characteristic curve (AUC). Input data included demographics, vital signs, injury type, and treatment received. The outcome variable was the discharge score on the Glasgow Outcome Scale-Extended., Results: The AUC for the prognostic models varied from 66.2% (k-nearest neighbors) to 86.5% (Bayesian generalized linear model). An increasing Glasgow Coma Scale score, increasing pulse oximetry values, and undergoing TBI surgery were predictive of a good recovery, while injuries suffered from a motor vehicle crash and increasing age were predictive of a poor recovery., Conclusions: The authors developed a TBI prognostic model with a substantial level of accuracy in a low-resource setting. Further research is needed to externally validate the model and test the algorithm as a clinical decision support tool.

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.

Background: Hepatitis B affects 257 million people worldwide. Mother-to-child hepatitis B virus (HBV) transmission is a preventable cause of substantial morbidity and mortality and poses greatest risk for developing chronic HBV infection. The World Health Organization recommends that all countries institute universal hepatitis B birth dose (HepB BD) vaccination during the first 24 h of life, followed by timely completion of routine immunization. The objective of this analysis was to assess the cost-effectiveness of adding HepB BD vaccination among sub-Saharan African refugee populations where the host country's national immunization policy includes HepB BD., Methods: We performed a cost-effectiveness analysis of three hepatitis B vaccination strategy scenarios for camp-based refugee populations in the African Region (AFR): routine immunization (RI), RI plus universal HepB BD, and RI plus HepB BD only for newborns of hepatitis B surface antigen-positive mothers identified through rapid diagnostic testing (RDT). We focused analyses on refugee populations living in countries that include HepB BD in national immunization schedules: Djibouti, Algeria and Mauritania. We used a decision tree model to estimate costs of vaccination and testing, and costs of life-years lost due to complications of chronic hepatitis B., Results: Compared with RI alone, addition of HepB BD among displaced Somali refugees in Djibouti camps would save 9807 life-years/year, with an incremental cost-effectiveness ratio (ICER) of 0.15 USD (US dollars) per life-year saved. The RI plus HepB BD strategy among Western Saharan refugees in Algerian camps and Malian refugees in Mauritania camps would save 27,108 life-years/year with an ICER of 0.11 USD and 18,417 life-years/year with an ICER of 0.16 USD, respectively. The RI plus RDT-directed HepB BD was less cost-effective than RI plus delivery of universal HepB BD vaccination or RI alone., Conclusions: Based on our model, addition of HepB BD vaccination is very cost-effective among three sub-Saharan refugee populations, using relative life-years saved. This analysis shows the potential benefit of implementing HepB BD vaccination among other camp-based refugee populations as more AFR countries introduce national HepB BD policies., Competing Interests: This statistical simulation did not involve human subjects.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objectives: Globally, hypertension affects one billion people and disproportionately burdens low-and middle-income countries. Despite the high disease burden in sub-Saharan Africa, optimal care models for diagnosing and treating hypertension have not been established. Emergency departments (EDs) are frequently the first biomedical healthcare contact for many people in the region. ED encounters may offer a unique opportunity for identifying high risk patients and linking them to care., Methods: Between July 2017 and March 2018, we conducted a prospective cohort study among patients presenting to a tertiary care ED in northern Tanzania. We recruited adult patients with a triage blood pressure ≥ 140/90 mmHg in order to screen for hypertension. We explored knowledge, attitudes and practices for hypertension using a questionnaire, and assessed factors associated with successful follow-up. Hypertension was defined as a single blood pressure measurement ≥ 160/100 mmHg or a three-time average of ≥ 140/90 mmHg. Uncontrolled hypertension was defined as a three-time average measurement of ≥ 160/100 mmHg. Successful follow-up was defined as seeing an outpatient provider within one month of the ED visit., Results: We enrolled 598 adults (mean age 59.6 years), of whom 539 (90.1%) completed the study. The majority (78.6%) of participants were aware of having hypertension. Many (223; 37.2%) had uncontrolled hypertension. Overall, only 236 (43.8%) of participants successfully followed-up within one month. Successful follow-up was associated with a greater understanding that hypertension requires lifelong treatment (RR 1.11; 95% CI 1.03,1.21) and inversely associated with greater anxiety about the future (RR 0.80; 95% CI 0.64,0.99)., Conclusion: In a northern Tanzanian tertiary care ED, the burden of hypertension is high, with few patients receiving optimal outpatient care follow-up. Multi-disciplinary strategies are needed to improve linkage to care for high-risk patients from ED settings., Competing Interests: The authors have declared that no competing interests exist.

Background: Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality., Methods and Results: Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables., Conclusions: The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country., Competing Interests: The authors have declared that no competing interests exist.

Background: Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed., Objective: To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda., Methods: Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed., Results: Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04)., Conclusion: Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.

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., Competing Interests: The authors have declared that no competing interests exist.

Aims: To develop Swahili versions of the Drinker Inventory of Consequences (DrInC) and evaluate its psychometric properties among a mixed population in Tanzania. Methods: A Swahili version of the DrInC was developed by a panel of bilingual Swahili and English speakers through translation and back-translation. The translated DrInC was administered to a sample of Tanzanian injury patients and a sample of the general population. The validity and reliability of the scale were tested using standard statistical methods. Results: The translated version of the DrInC questionnaire was found to have outstanding domain coherence and language clarity. The tested scale and subscales have adequate reliability (>0.85). Confirmatory factor analysis (CFA) confirmed the five-factor solution by yielding adequate results. DrInC score is statistically significantly correlated with alcohol consumption quantity and the AUDIT score, suggesting that DrInC is able to predict alcohol use as well. Conclusions: This study presents the first validation of the DrInC questionnaire with injury patients and a general population and the first adaptations of the DrInC questionnaire in the Tanzanian and Swahili setting. DrInC instrument was found to have satisfactory psychometric properties, resulting in a new medical and social research tool in this setting.

Road traffic crashes (RTCs) are a leading cause of death and disability. In low- and middle-income countries, vulnerable road users are commonly involved in injurious RTCs. This study describes epidemiological and built environment analysis (BEA) of in Galle, Sri Lanka. After ethical and police permission, police data were collected and descriptive statistics tabulated. Spatial analysis identified hot spots and BEA was conducted at each location. Seven hundred and fifty-two victim data from 389 reported RTCs were collected. Most victims were male (91%) 21-50 years of age (>70%). Forty-nine percent of RTCs were non-grievous. Crashes commonly included motorcycles (33.9%), three-wheelers (18.3%) or cars (14.4%). Most victims were drivers (33.4%) or pedestrians (21.3%). Factors contributing to RTCs include aggressive driving (44.5%) or speeding (42.7%). All hotspots were in urban areas, and most were at intersections (63%). Further analysis of hot spots is necessary to identify areas for intervention.

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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.

Background: In Mozambique, and other low-income countries (LICs), there is little information on the burden of child maltreatment (CM). Emergency care services (ECS) play an important role in recognizing, treating, and intervening in situations of CM. We aim to identify knowledge, attitudes, and practices regarding CM among health care providers in ECS at Mavalane General Hospital in Maputo, Mozambique., Methods: This exploratory cross-sectional study evaluates the knowledge, attitudes, and practices of health care providers to diagnose and treat cases of CM. A 25 min, pilot-tested verbal interview questionnaire was administered to 49 physicians and nurses working in ECS at Mavalane General Hospital. Interviews were completed between October-November 2010. Data were managed and analyzed in SPSS 14.0 and descriptive statistics were generated., Results: Of 49 health care providers, 83.6% reporting receiving no, or very little CM education or training. Only 61.2% had knowledge of physical abuse as a main form of child maltreatment and 38.8% were able to identify corresponding symptoms of physical abuse. Sexual abuse as a main form of CM was mentioned by 26.5 and 2% cited its symptoms. While 87.7% of health care providers strongly agreed or agreed that they hold an important role in preventing CM, 51.1% also strongly disagreed or disagreed that they feel confident diagnosing and treating CM cases. In regards to follow-up, 14.3% strongly disagreed or disagreed that they know where to refer victims for further follow-up and an additional 14.3% did not know whether they agreed or disagreed., Conclusion: This study revealed knowledge gaps in emergency health care provider knowledge of the main forms of CM and their symptoms. The fact that a majority of health care providers in our sample did not receive information specific to CM in their medical education and training could explain this gap, as well as their unawareness of where to refer victims. Given that health care providers believe they play an important role in identifying and treating CM, future research should focus on raising physician awareness of CM and developing education and training materials grounded in cultural contexts to build response capacity in Mozambique and other LICs.

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.

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 Author 2017. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Objectives: Studies of health geography are important in the planning and allocation of emergency health services. The geographical distribution of health facilities is an important factor in timely and quality access to emergency services; therefore, the present study analyzed the emergency health care network in Brazil, focusing the analysis at the roles of small hospitals (SHs)., Study Design: Cross-sectional ecological study., Methods: Data were collected from 9429 hospitals of which 3524 were SHs and 5905 were high-complexity centers (HCCs). For analytical purposes, we considered four specialties when examining the proxies of emergency care capability: adult, pediatrics, neonatal, and obstetric. We analyzed the spatial distribution of hospitals, identifying municipalities that rely exclusively on SHs and the distance of these cities from HCCs., Results: More than 14 and 30 million people were at least 120 km away from HCCs with an adult intensive care unit (ICU) and pediatric ICU, respectively. For neonatal care distribution, 12% of the population was more than 120 km away from a health facility with a neonatal ICU. The maternities situation is different from other specialties, where 81% of the total Brazilian population was within 1 h or less from such health facilities., Conclusion: Our results highlighted a polarization in distribution of Brazilian health care facilities. There is a concentration of hospitals in urban areas more developed and access gaps in rural areas and the Amazon region. Our results demonstrate that the distribution of emergency services in Brazil is not facilitating access to the population due to geographical barriers associated with great distances., (Copyright © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda., Methods: We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality., Results: 563 TBI patients were enrolled from 1 June- 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours., Conclusions: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.