Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers.

Over 98% of stillbirths and neonatal deaths occur in Low- and Middle-Income Countries, such as Tanzania. Despite the profound burden of perinatal loss in these regions, access to facility or community-based palliative and psychosocial care is poor and understudied. In this study we explore perinatal loss through the lens of front-line healthcare providers, to better understand the knowledge and beliefs that guide their engagement with bereaved families. A Knowledge Attitudes and Practices survey addressing perinatal loss in Tanzania was developed, translated into Swahili, and administered over a 4-month period to healthcare professionals working at the Kilimanjaro Christian Medical Center (KCMC). Results were entered into REDCap and analyzed in R Studio. 74 providers completed the survey. Pediatric providers saw a yearly average of 5 stillbirths and 32.7 neonatal deaths. Obstetric providers saw an average of 11.5 stillbirths and 13.12 neonatal deaths. Most providers would provide resuscitation beginning at 28 weeks gestational age. Respondents estimated that a 50% chance of survival for a newborn occurred at 28 weeks both nationally and at KCMC. Most providers felt that stillbirth and neonatal mortality were not the mother's fault (78.4% and 81.1%). However, nearly half (44.6%) felt that stillbirth reflects negatively on the woman and 62.2% agreed that women are at higher risk of abuse or abandonment after stillbirth. A majority perceived that women wanted hold their child after stillbirth (63.0%) or neonatal death (70.3%). Overall, this study found that providers at KCMC perceived that women are at greater risk of psychosocial or physical harm following perinatal loss. How women can best be supported by both the health system and their community remains unclear. More research on perinatal loss and bereavement in LMICs is needed to inform patient-level and health-systems interventions addressing care gaps unique to resource-limited or non-western settings.

Impact of the COVID-19 pandemic in childhood and adolescent cancer care in northern Tanzania: a cross-sectional study.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic has strained healthcare systems and presented unique challenges for children requiring cancer care, particularly in low- and middle-income countries. This study aimed to assess the impact of the COVID-19 pandemic on access to cancer care for children and adolescents in Northern Tanzania. METHODS: In this cross-sectional study, we assessed the demographic and clinical characteristics of 547 pediatric and adolescent cancer patients (ages 0-19 years old) between 2016 and 2022 using the population-based Kilimanjaro Cancer Registry (KCR). We categorized data into pre-COVID-19 (2016-2019) and COVID-19 (2020-2022) eras, and performed descriptive analyses of diagnostic, treatment, and demographic information. A secondary analysis was conducted on a subset of 167 patients with stage of diagnosis at presentation. RESULTS: Overall admissions nearly doubled during the pandemic (n = 190 versus 357). The variety of diagnoses attended at KCMC increased during the pandemic, with only five groups of diseases reported in 2016 to twelve groups of diseases in 2021. Most patients were diagnosed at a late stage (stage III or IV) across eras, with the proportion of under-five years old patients increasing late-diagnoses from 29.4% (before the pandemic), 52.8% (during the pandemic), when compared to the overall cohort. Around 95% of children in this age category reported late-stage diagnosis during the pandemic. Six out of the twelve cancer site groups also reported an increase in late-stage diagnosis. During the pandemic, the proportion of children receiving surgery increased from 15.8 to 30.8% (p < 0.001). CONCLUSION: Childhood and adolescent cancer care changed in Northern Tanzania during the COVID-19 pandemic, with increased late-stage diagnoses presentations among younger patients and the increased use of surgical therapies in the context of a growing practice. Understanding the impact of the COVID-19 pandemic on pediatric and adolescent cancer care can help us better adapt healthcare systems and interventions to the emerging needs of children and adolescents with cancer in the midst of a health crisis.

Applicability of machine learning algorithm to predict the therapeutic intervention success in Brazilian smokers.

Smoking cessation is an important public health policy worldwide. However, as far as we know, there is a lack of screening of variables related to the success of therapeutic intervention (STI) in Brazilian smokers by machine learning (ML) algorithms. To address this gap in the literature, we evaluated the ability of eight ML algorithms to correctly predict the STI in Brazilian smokers who were treated at a smoking cessation program in Brazil between 2006 and 2017. The dataset was composed of 12 variables and the efficacies of the algorithms were measured by accuracy, sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve. We plotted a decision tree flowchart and also measured the odds ratio (OR) between each independent variable and the outcome, and the importance of the variable for the best model based on PPV. The mean global values for the metrics described above were, respectively, 0.675±0.028, 0.803±0.078, 0.485±0.146, 0.705±0.035 and 0.680±0.033. Supporting vector machines performed the best algorithm with a PPV of 0.726±0.031. Smoking cessation drug use was the roof of decision tree with OR of 4.42 and importance of variable of 100.00. Increase in the number of relapses also promoted a positive outcome, while higher consumption of cigarettes resulted in the opposite. In summary, the best model predicted 72.6% of positive outcomes correctly. Smoking cessation drug use and higher number of relapses contributed to quit smoking, while higher consumption of cigarettes showed the opposite effect. There are important strategies to reduce the number of smokers and increase STI by increasing services and drug treatment for smokers.

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A qualitative exploration of alcohol, gender, stigma, and sexual assault in Moshi, Tanzania.

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. In-depth interviews were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach. Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use encouraged for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men. Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context while treatment for men should be cognizant of the social pressures to drink. Strategies to address and/or mitigate these factors should be incorporated in subsequent care and interventions.

Development and validation of a minimum requirements checklist for snakebite envenoming treatment in the Brazilian Amazonia.

BACKGROUND: Currently, antivenoms are the only specific treatment available for snakebite envenoming. In Brazil, over 30% of patients cannot access antivenom within its critical care window. Researchers have therefore proposed decentralizing to community health centers to decrease time-to-care and improve morbidity and mortality. Currently, there is no evidence-based method to evaluate the capacity of health units for antivenom treatment, nor what the absolute minimum supplies and staff are necessary for safe and effective antivenom administration and clinical management. METHODS: This study utilized a modified-Delphi approach to develop and validate a checklist to evaluate the minimum requirements for health units to adequately treat snakebite envenoming in the Amazon region of Brazil. The modified-Delphi approach consisted of four rounds: 1) iterative development of preliminary checklist by expert steering committee; 2) controlled feedback on preliminary checklist via expert judge survey; 3) two-phase nominal group technique with new expert judges to resolve pending items; and 4) checklist finalization and closing criteria by expert steering committee. The measure of agreement selected for this study was percent agreement defined a priori as ≥75%. RESULTS: A valid, reliable, and feasible checklist was developed. The development process highlighted three key findings: (1) the definition of community health centers and its list of essential items by expert judges is consistent with the Brazilian Ministry of Health, WHO snakebite strategic plan, and a general snakebite capacity guideline in India (internal validity), (2) the list of essential items for antivenom administration and clinical management is feasible and aligns with the literature regarding clinical care (reliability), and (3) engagement of local experts is critical to developing and implementing an antivenom decentralization strategy (feasibility). CONCLUSION: This study joins an international set of evidence advocating for decentralization, adding value in its definition of essential care items; identification of training needs across the care continuum; and demonstration of the validity, reliability, and feasibility provided by engaging local experts. Specific to Brazil, further added value comes in the potential use of the checklist for health unit accreditation as well as its applications to logistics and resource distribution. Future research priorities should apply this checklist to health units in the Amazon region of Brazil to determine which community health centers are or could be capable of receiving antivenom and translate this expert-driven checklist and approach to snakebite care in other settings or other diseases in low-resource settings.

A systematic review and cross-sectional survey of rehabilitation resources for injury patients in the Kilimanjaro Region of Tanzania.

PURPOSE: An estimated 10 million people across Tanzania have a condition that would benefit from rehabilitative care. However, access to rehabilitation remains inadequate to meet the needs of Tanzania's population. The goal of this study was to identify and characterize rehabilitation resources available to injury patients in the Kilimanjaro region of Tanzania. METHODS: We used two approaches to identify and characterize rehabilitation services. First, we conducted a systematic review of peer-reviewed and gray literature. Second, we administered a questionnaire to rehabilitation clinics identified through the systematic review as well as through staff at Kilimanjaro Christian Medical Centre. RESULTS: Our systematic review identified eleven organizations offering rehabilitation services. Eight of these organizations responded to our questionnaire. Seven of the surveyed organizations provide care to patients with spinal cord injuries, short term disability, or permanent movement disorders. Six offer diagnostic and treatment procedures to injured and disabled patients. Six offer homecare support. Two require no payment. Only three accept health insurance. None offer financial support. CONCLUSIONS: There is a sizable portfolio of health clinics offering rehabilitation services to injury patients in the Kilimanjaro region. However, there remains an ongoing need to connect more patients in the region to long-term rehabilitative care.IMPLICATIONS FOR REHABILITATIONInjury is a leading cause of death and disability worldwide and disproportionately affects populations in low- and middle-income countries (LMICs).Rehabilitation is an essential component of injury care, yet an estimated 50% of patients in LMICs who need rehabilitation do not receive it.This study offers insight into the availability and use of rehabilitative services in an LMIC with a substantial injury burden.

Scaling up antivenom for snakebite envenoming in the Brazilian Amazon: a cost-effectiveness analysis.

Background: Snakebite envenoming (SBE) affects nearly three million people yearly, causing up to 180,000 deaths and 400,000 cases of permanent disability. Brazil's state of Amazonas is a global hotspot for SBE, with one of the highest annual incidence rates per 100,000 people, worldwide. Despite this burden, snake antivenom remains inaccessible to a large proportion of SBE victims in Amazonas. This study estimates the costs, and health and economic benefits of scaling up antivenom to community health centers (CHCs) and hospitals in the state. Methods: We built a decision tree model to simulate three different antivenom scale-up scenarios: (1) scale up to 95% of hospitals, (2) scale up to 95% of CHCs, and (3) scale up to 95% of hospitals and 95% of CHCs. We consider each scenario with and without a 10% increase in demand for antivenom among SBE victims. For each scenario, we model the treatment costs averted, deaths averted, and disability-adjusted life years (DALYs) averted from a societal, health system, and patient perspective relative to the status quo and over a time horizon of one year. For each scenario and perspective, we also calculate the incremental cost per DALY averted and per death averted. We use a willingness to pay threshold equal to the 2022 gross domestic product (GDP) per capita of Brazil. Findings: Scaling up antivenom to 95% of hospitals averts up to 2022 DALYs, costs up to USD $460 per DALY averted from a health system perspective, but results in net economic benefits up to USD $4.42 million from a societal perspective. Scaling up antivenom to 95% of CHCs averts up to 3179 DALYs, costs up to USD $308 per DALY averted from a health system perspective, but results in net economic benefits up to USD $7.35 million from a societal perspective. Scaling up antivenom to 95% of hospitals and CHCs averts up to 3922 DALYs, costs up to USD $328 per DALY averted from a health system perspective, but results in net economic benefits up to USD $8.98 million from a societal perspective. Interpretation: All three antivenom scale up scenarios - scale up to 95% of hospitals, scale up to 95% of CHCs, and scale up to 95% of hospitals and 95% of CHCs - avert a substantial proportion of the SBE burden in Amazonas and are cost-saving from a societal perspective and cost-effective from a health system perspective. Funding: W.M. and J.S. were funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq productivity scholarships). W.M. was funded by Fundação de Amparo à Pesquisa do Estado do Amazonas (PRÓ-ESTADO, call n. 011/2021-PCGP/FAPEAM, call n. 010/2021-CT&I ÁREAS PRIORITÁRIAS, call n. 003/2022-PRODOC/FAPEAM, POSGRAD/FAPEAM) and by the Ministry of Health, Brazil (Proposal No. 733781/19-035). Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW011944. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Barriers and facilitators for developing a prehospital emergency care system evaluation tool (PEC-SET) for low-resource settings: a qualitative analysis.

OBJECTIVES: Strengthening of emergency care systems, including prehospital systems, can reduce death and disability. We aimed to identify perspectives on barriers and facilitators relating to the development and implementation of a prehospital emergency care system assessment tool (PEC-SET) from prehospital providers representing several South and Southeast (SE) Asian countries. DESIGN: We conducted a qualitative study using focus group discussions (FGD) informed by the Consolidated Framework for Implementation Research (CFIR). FGDs were conducted in English, audioconferencing/videoconferencing was recorded, transcribed verbatim and coded using an inductive and deductive approach. Participants suggested specific elements to be measured within three main 'pillars' of disease conditions proposed by the research team of the tool being developed (cardiovascular, trauma and perinatal emergencies). SETTING: We explored the perspectives of medical directors in six low-income and middle-income countries (LMICs) in South and SE Asia. PARTICIPANTS: A total of 16 participants were interviewed (1 Vietnam, 4 Philippines, 4 Thailand, 5 Malaysia, 1 Indonesia and 1 Pakistan) as a part of 4 focus groups. RESULTS: Themes identified within the four CFIR constructs included: (1) Intervention characteristics: importance of developing an contextually specific tool, need for generalisability, trialling in one geographical area or with one pillar before expanding; (2) Inner setting: data transfer barriers, workforce shortages; (3) Outer setting: underdevelopment of EMS nationally; need for further EMS system development prior to implementing a tool and (4) Individual characteristics: lack of buy-in by prehospital personnel. Elements proposed by participants included both process and outcome measures. CONCLUSIONS: Through the CFIR framework, we identified several themes which can provide a basis for codeveloping a PEC-SET for LMICs with local stakeholders. This work may inform development of quality improvement tools in LMIC PEC systems.

Correction: Applicability of machine learning technique in the screening of patients with mild traumatic brain injury.

[This corrects the article DOI: 10.1371/journal.pone.0290721.].

Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania.

BACKGROUND: Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. OBJECTIVE: The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. METHODS: This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. RESULTS: Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. CONCLUSION: Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

Validation of a culturally sensitive, Swahili-translated instrument to assess suicide risk among adults living with HIV in Tanzania.

In Tanzania, there are high rates of suicidal thoughts and behavior among people living with HIV (PLWH), yet few instruments exist for effective screening and referral. To address this gap, we developed and validated Swahili translations of the Columbia Suicide Severity Rating Scale (C-SSRS) Screen Version and two accompanying scales assessing self-efficacy to avoid suicidal action and reasons for living. We administered a structured survey to 80 PLWH attending two HIV clinics in Moshi, Tanzania. Factor analysis of the items revealed four subscales: suicide intensity, self-efficacy to avoid suicide, fear and social concern about suicide, and family and spirituality deterrents to suicide. The area under the receiver operating curve showed only suicide intensity, and fear and social concern met the prespecified cutoff of ≥0.7 in accurately identifying patients with a plan and intent to act on suicidal thoughts. This study provides early evidence that brief screening of intensity of suicidality in the past month, assessed by the C-SSRS Screen Version, is a strong, resource-efficient strategy for identifying suicide risk in the Tanzanian setting. Patients who report little fear of dying and low concern about social perceptions of suicide may also be at increased risk.

Alcohol use among emergency medicine department patients in Tanzania: A comparative analysis of injury versus non-injury patients.

BACKGROUND: Alcohol is a leading behavioral risk factor for death and disability worldwide. Tanzania has few trained personnel and resources for treating unhealthy alcohol use. In Emergency Medicine Departments (EMDs), alcohol is a well-known risk factor for injury patients. At Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania, 30% of EMD injury patients (IP) test positive for alcohol upon arrival to the ED. While the IP population is prime for EMD-based interventions, there is limited data on if non-injury patients (NIP) have similar alcohol use behavior and potentially benefit from screening and intervention as well. METHODS: This was a secondary analysis of a systematic random sampling of adult (≥18 years old), KiSwahili speaking, KCMC EMD patients surveyed between October 2021 and May 2022. When medically stable and clinically sober, participants provided informed consent. Information on demographics (sex, age, years of education, type of employment, income, marital status, tribe, and religion), injury status, self-reported alcohol use, and Alcohol Use Disorder (AUD) Identification Test (AUDIT) scores were collected. Descriptive statistics were analyzed in RStudio using frequencies and proportions. RESULTS: Of the 376 patients enrolled, 59 (15.7%) presented with an injury. The IP and NIP groups did not differ in any demographics except sex, an expected difference as females were intentionally oversampled in the original study design. The mean [SD] AUDIT score (IP: 5.8 [6.6]; NIP: 3.9 [6.1]), drinks per week, and proportion of AUDIT ≥8 was higher for IP (IP:37%; NIP: 21%). However, alcohol preferences, drinking quantity, weekly expenditure on alcohol, perceptions of unhealthy alcohol use, attempts and reasons to quit, and treatment seeking were comparable between IPs and NIPs. CONCLUSION: Our data suggests 37% of injury and 20% of non-injury patients screen positive for harmful or hazardous drinking in our setting. An EMD-based alcohol treatment and referral process could be beneficial to reduce this growing behavioral risk factor in non-injury as well as injury populations.

"A Man Never Cries": A Mixed-Methods Analysis of Gender Differences in Depression and Alcohol Use in Moshi, Tanzania.

Background: Unhealthy alcohol use negatively impacts many components of health and wellness, including mental health conditions like major depressive disorder (MDD). Globally, gender differences are common for both alcohol use behaviors and MDD, but these differences have not been studied within Moshi, Tanzania. To provide more effective and culturally appropriate mental health treatments, gender nuances around these conditions must be known. As such, this study aims to explore gender differences in MDD, alcohol use, and other aspects of mental well-being among patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. Methods: Six hundred and seventy-six patients presenting for care at the KCMC Emergency Department (ED) and Reproductive Health Centre (RHC) were enrolled in this mixed-methods study between October 2021 and May 2022. Patients were selected through systematic random sampling and completed quantitative surveys including the Alcohol Use Disorder Identification Test (AUDIT) and the Patient Health Questionnaire 9 (PHQ-9). Nineteen patients were purposively chosen from the study population to participate in in-depth interviews (IDIs) exploring topics related to alcohol use, gender, and depression. Descriptive frequencies, univariate log-binomial regressions, and a linear regression model were used to analyze quantitative data, all of which were analyzed in RStudio. A grounded theory approach was used to analyze all IDIs in NVivo. Results: Average [SD] PHQ-9 scores were 7.22 [5.07] for ED women, 4.91 [4.11] for RHC women, and 3.75 [4.38] among ED men. Similarly, ED women held the highest prevalence of MDD (25%) as compared to RHC women (11%) and ED men (7.9%) (p<0.001). Depressive symptoms were associated with higher AUDIT scores only for ED men (R2 = 0.11, p<0.001). Our qualitative analysis showed that while present for women, social support networks were notably absent for men in Moshi, the lack of which was seen to play a role in alcohol use. For men, alcohol was described as a coping mechanism for stress. Conclusion: Intersectionality of gender, alcohol use, and depression is influenced by sociocultural and behavioral norms in Moshi. As such, multi-layered, gender-differentiated programming should be considered for the treatment of substance use and mental health conditions in this region.

A feasibility assessment of a traumatic brain injury predictive modelling tool at Kilimanjaro Christian Medical Center and Duke University Hospital.

Traumatic brain injury (TBI) is the most common cause of death and disability globally. TBI, which disproportionately affects low middle-income countries (LMIC), uses significant amounts of health system resources in costly care and management. Innovative solutions are required to address this high burden of TBI. One possible solution is prognostic models which enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a TBI prognostic model developed in Tanzania for use by Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke-affiliated healthcare providers using human centered design methodology. Duke participants were included to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows, co-design interviews were conducted with emergency physicians and nursing staff at KCMC and Duke. Qualitatively, the TBI tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Our knowledge translation method was guided using the knowledge-to-action framework. Of the 21 participants interviewed, 12 were associated with Duke Hospital, and 9 from Kilimanjaro Christian Medical Centre. Emerging from the data were 6 themes that impacted the implementation of the TBI tool: access, barriers, facilitators, use of the TBI tool, outer setting, and inner setting. To our knowledge, this is the first study to investigate the pre-implementation of a sub-Saharan Africa (SSA) data- based TBI prediction tool using human centered design methodology. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC.

Healthcare provider perspective on barriers and facilitators in the care of pediatric injury patients at a tertiary hospital in Northern Tanzania: A qualitative study.

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. The purpose of this study was to identify the barriers and the facilitators in pediatric injury care at Kilimanjaro Christian Medical Center (KCMC), a tertiary zonal referral hospital in Northern Tanzania. In this study, focus group discussions (FGDs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the barriers and facilitators in pediatric injury care. Five FGDs were completed from February 2021 to July 2021. Participants (n = 30) were healthcare providers from the emergency department, burn ward, surgical ward, and pediatric ward. De-identified transcripts were analyzed with team-based, applied thematic analysis using qualitative memo writing and consensus discussions. Our study found barriers that impeded pediatric injury care were: lack of pediatric-specific injury training and care guidelines, lack of appropriate pediatric-specific equipment, staffing shortages, lack of specialist care, and complexity of cases due to pre-hospital delays in patients presenting for care due to cultural and financial barriers. Facilitators that improved pediatric injury care were: team cooperation and commitment, strong priority and triage processes, benefits of a tertiary care facility, and flexibility of healthcare providers to provide specialized care if needed. The data highlights barriers and facilitators that could inform interventions to improve the care of pediatric injury patients in Northern Tanzania such as: increasing specialized provider training in pediatric injury management, the development of pediatric injury care guidelines, and improving access to pediatric-specific technologies and equipment.

Clinical evaluation of the alcohol use disorders identification test (AUDIT) in Moshi, Tanzania.

BACKGROUND: Alcohol use disorder is a major cause of morbidity and mortality in low- and middle-income countries. Alcohol screening using a validated tool is a useful way to capture high-risk patients and engage them in early harm reduction interventions. Our objectives were to 1) evaluate the psychometric evidence the Alcohol Use Disorders Identification Test (AUDIT) and its subscales in the general population of Moshi, Tanzania, and 2) evaluate the usefulness of the tool at predicting alcohol-related harms. METHODS: Two hundred and fifty-nine adults living in Moshi, Tanzania were included in the study. We used the AUDIT and its subscales to determine the classification of harmful and hazardous drinking. To analyze the internal structure of AUDIT and the model adequacy we used Confirmatory Factor Analysis (CFA). The reliability of AUDIT was analyzed for Cronbach's alpha, Omega 6 and Composite Reliability. The optimal cut off point for the AUDIT was determined by the receiver operating characteristic (ROC) curve, using the Youden approach to maximize sensitivity and specificity. RESULTS: The median score of the AUDIT was 1 (inter-quartile range: 0-7). The internal structure of the AUDIT showed factor loadings ranging from 0.420 to 0.873. Cronbach's alpha, Omega and Composite Reliability produced values above 0.70. The Average Variance Extracted was 0.530. For the AUDIT, a score of 8 was identified as the ideal cut-off value in our population. CONCLUSIONS: This study validates AUDIT in the general population of Moshi and is one of the only studies in Africa to include measures of the internal structure of the AUDIT and its subscales.

Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors.

Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.

A mixed-methods comparison of gender differences in alcohol consumption and drinking characteristics among patients in Moshi, Tanzania.

Excessive alcohol use stands as a serious threat to individual and community well-being, having been linked to a wide array of physical, social, mental, and economic harms. Alcohol consumption differs by gender, a trend seen both globally and in Moshi, Tanzania, a region with especially high rates of intake and few resources for alcohol-related care. To develop effective gender-appropriate treatment interventions, differences in drinking behaviors between men and women must be better understood. Our study aims to identify and explore gender-based discrepancies in alcohol consumption among Kilimanjaro Christian Medical Center (KCMC) patients. A systematic random sampling of adult patients presenting to KCMC's Emergency Department (ED) or Reproductive Health Center (RHC) was conducted from October 2021 until May 2022. Patients answered demographic and alcohol use-related questions and completed brief surveys, including the Alcohol Use Disorder Identification Test (AUDIT). Through purposeful sampling, 19 individuals also participated in in-depth interviews (IDIs) that focused on identifying gender differences in alcohol use. Quantitative data was analyzed in RStudio through descriptive frequencies, proportions, ANOVA, and Chi-squared tests, while IDIs were analyzed in Nvivo following a grounded theory approach. During the 8-month data collection timeline, 676 patients were enrolled. Men and women patients at KCMC's ED and RHC were found to have significant differences in their alcohol use behaviors. For our quantitative data, this included lower average AUDIT scores among women (average [SD] AUDIT scores were 6.76 [8.16] among ED men, 3.07 [4.76] among ED women, and 1.86 [3.46] among RHC women). A subsequent IDI analysis revealed greater social restrictions around women's drinking and more secretive alcohol use behaviors for where and when women would drink. For men, excess drinking was normalized within Moshi, tied to men's social interactions with other men, and generally motivated by stress, social pressure, and despair over lack of opportunity. Significant gender differences in drinking behaviors were found, primarily influenced by sociocultural norms. These dissimilarities in alcohol use suggest that future alcohol-related programs should incorporate gender in their conceptualization and implementation.

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A Qualitative Exploration of Alcohol, Gender, Stigma, and Sexual Assault in Moshi, Tanzania.

Background: Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. Methods: In-depth interviews (IDIs) were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach. Results: Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use normalized for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men. Conclusion: Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context and incorporate strategies to address and/or mitigate these harms in subsequent care and interventions.