Gastric cancer in Sub-Saharan Africa - a systematic review of primary data.

Introduction: Gastric cancer (GC) is the third leading cause of global cancer-related mortality. Despite the shifting burden of GC to low-and middle-income countries, the data regarding incidence, treatment, and outcomes in these settings are sparse. The primary aim of this systematic review was to aggregate all available data on GC in sub-Saharan Africa (SSA) to describe the variability in incidence across the region. Methods: Studies reporting population-based primary data on GC in SSA were considered. The inclusion was limited to primary studies published between January 1995 and March 2022 which comprised of adult patients in SSA with GC. Studies without accessible full text in either French or English language were excluded. Unadjusted GC incidence rates with their standard errors for each study were recalculated from the crude numerators and denominators provided in individual studies. Results: A total of 5,626 articles were identified in the initial search, of which, 69 studies were retained. Reported incidence rates ranged from a high of 5.56 GC cases per 100,000 in Greater Meru Kenya to a low of 0.04 GC cases per 100,000 people in Benin City Nigeria. The overall crude pooled incidence was 1.20 GC cases per 100, 000 (95%CI 1.15-1.26) with a variability of 99.83% (I2 p < 0.001). From the 29 high-quality population-based registry studies the crude pooled incidence was 1.71 GC cases per 100,000 people (95%CI 1.56-21.88) with a variability of 99.60%. Conclusion: This systemic review demonstrates that GC incidence is highly variable across SSA. The limited data on GC treatment, mortality, and survival presents a significant challenge to providing a complete epidemiologic description of the burden of GC in SSA. There is a need for further robust data collection, exploration, and research studies on cancer care in SSA, with continued assessment of primary data availability.

Road Traffic Injuries in South Africa: A Complex Global Health Crisis.

1.3 million people die each year as a result of Road traffic crashes. Road Traffic Injuries are a global health crisis with 90% of global deaths affecting LMICs. Sustainable Development Goal 3.6 focuses on reducing road injury and death. The global plan is based on the Safe Systems approach. In South Africa, the burden of crashes on the health system and society is particularly high with a population death rate of 20.7 per 100 000 population. Understanding local context and culture is critical. Rurality, distorted urban planning, higher travel exposure and alcohol usage disproportionately impact racial and ethnic minorities. Pedestrian safety is a key priority. There is a critical need for the global health community to take an active role in advocacy in order to achieve SDG 3.6 by 2030.

An increase in electrical burns during the covid lockdown in Western Cape, South Africa.

BACKGROUND: A severe Covid lockdown in South Africa may have changed burn patterns due to the downturn of the economy and stay-at-home policies. We describe the volume and type of burn admitted to a tertiary hospital before and during the Covid lockdown. MATERIALS AND METHODS: This was a retrospective study from before (April 2019-March 2020) and during (April 2020-March 2021) the Covid pandemic. Patient demographics, burn etiology, and clinical outcomes were described. Logistic regression was used to model associations between burn etiology and the Covid period. RESULTS: Of 544 burns, 254 (46.7%) occurred before and 290 (53.3%, p = 0.051) during Covid. The proportion of electrical burns doubled during Covid n = 20, 32.3% vs n = 42, 67.7%, (p = 0.053) periods. At least half were associated with suspected cable or copper theft. On multivariate analysis, flame burns (OR=2.42, p < 0.001), electrical burns (OR=4.88, p < 0.001), and paying patients (OR=4.21, p < 0.001) were more likely to be associated with the Covid period. CONCLUSION: Electrical burns doubled during Covid, potentially related to an increase in cable and copper wire theft, a phenomenon described during hard economic times in other settings. More studies to understand this potential relationship are indicated to prepare burn centers during future pandemics and/or economic hardship.

Community support for injured patients: A scoping review and narrative synthesis.

BACKGROUND: Community-based peer support (CBPS) groups have been effective in facilitating access to and retention in the healthcare system for patients with HIV/AIDS, cancer, diabetes, and other communicable and non-communicable diseases. Given the high incidence of morbidity that results from traumatic injuries, and the barriers to reaching and accessing care for injured patients, community-based support groups may prove to be similarly effective in this population. OBJECTIVES: The objective of this review is to identify the extent and impact of CBPS for injured patients. ELIGIBILITY: We included primary research on studies that evaluated peer-support groups that were solely based in the community. Hospital-based or healthcare-professional led groups were excluded. EVIDENCE: Sources were identified from a systematic search of Medline / PubMed, CINAHL, and Web of Science Core Collection. CHARTING METHODS: We utilized a narrative synthesis approach to data analysis. RESULTS: 4,989 references were retrieved; 25 were included in final data extraction. There was a variety of methodologies represented and the groups included patients with spinal cord injury (N = 2), traumatic brain or head injury (N = 7), burns (N = 4), intimate partner violence (IPV) (N = 5), mixed injuries (N = 5), torture (N = 1), and brachial plexus injury (N = 1). Multiple benefits were reported by support group participants; categorized as social, emotional, logistical, or educational benefits. CONCLUSIONS: Community-based peer support groups can provide education, community, and may have implications for retention in care for injured patients.

Governance for injury care systems in Ghana, South Africa and Rwanda: development and pilot testing of an assessment tool.

OBJECTIVES: This study aims to evaluate health systems governance for injury care in three sub-Saharan countries from policymakers' and injury care providers' perspectives. SETTING: Ghana, Rwanda and South Africa. DESIGN: Based on Siddiqi et al's framework for governance, we developed an online assessment tool for health system governance for injury with 37 questions covering health policy and implementation under 10 overarching principles of strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness of institutions, equity, effectiveness or efficiency, accountability, ethics and intelligence and information. A literature review was also done to support the scoring. We derived scores using two methods-investigator scores and respondent scores. PARTICIPANTS: The tool was sent out to purposively selected stakeholders, including policymakers and injury care providers in Ghana, Rwanda and South Africa. Data were collected between October 2020 and February 2021. PRIMARY AND SECONDARY OUTCOMES: Investigator-weighted and respondent percentage scores for health system governance for injury care. This was calculated for each country in total and per principle. RESULTS: Rwanda had the highest overall investigator-weighted percentage score (70%), followed by South Africa (59%). Ghana had the lowest overall investigator score (48%). The overall results were similar for the respondent scores. Some areas, such as participation and consensus, scored high in all three countries, while other areas, such as transparency, scored very low. CONCLUSION: In this multicountry governance survey, we provide insight into and evaluation of health system governance for trauma in three low- and middle-income countries (LMICs) in sub-Saharan Africa. It highlights areas of improvement that need to be prioritised, such as transparency, to meet the high burden of trauma and injuries in LMICs.

Social Determinants of Seeking and Reaching Injury Care in South Africa: A Community-Based Qualitative Study.

Background: Timely access to quality injury care saves lives and prevents disabilities. The impact of social determinants of health on the high injury prevalence in South Africa is well documented, however, evidence of their role in accessing injury care is lacking. This study explored the social determinants of seeking and reaching injury care in South Africa. Methods: This was a qualitative study involving rural and urban patients, community members, and healthcare providers in Western Cape, South Africa. Data were obtained through semi-structured interviews and focus group discussions using an interview guide informed by the four-delays framework. Inductive and deductive approaches were used for thematic analysis. Results: A total of 20 individual interviews and 5 focus group discussions were conducted. There were 28 males (individual interviews: 13; focus groups: 15) and 22 females (individual interviews: 7; focus groups: 15), and their mean age was 41 (standard deviation ±15) years. Barriers to seeking and reaching injury care cut across five social determinants of health domains: healthcare access and quality; neighbourhood and environment; social and community context; education; and economic stability. The most prominent social determinants of seeking and reaching injury care were related to healthcare access and quality, including perceived poor healthcare quality, poor attitude of healthcare workers, long waiting time, and ambulance delays. However, there was a strong interconnection between these and neighbourhood and environmental determinants such as safety concerns, high crime rates, gangsterism, lack of public transportation, and social and community factors (presence/absence of social support and alcohol use). Barriers related to education and economic stability were less prevalent. Conclusion: We found a substantial role of neighbourhood, social, and community factors in seeking and reaching injury care. Therefore, efforts aimed at improving access to injury care and outcomes must go beyond addressing healthcare factors to include other social determinants and should involve collaborations with multiple sectors, including the community, the police, the transport department, and alcohol regulation agencies.

Mapping access to care and identification of barriers for traumatic brain injury in a South African township.

RATIONALE: South Africa has a high traumatic injury burden resulting in a significant number of persons suffering from traumatic brain injury (TBI). TBI is a time-sensitive condition requiring a responsive and organized health system to minimize morbidity and mortality. This study outlined the barriers to accessing TBI care in a South African township. METHODS: This was a multimethod study. A facility survey was carried out on health facilities offering trauma care in Khayelitsha township, Cape Town, South Africa. Perceived barriers to accessing TBI care were explored using qualitative interviews and focus group discussions. The four-delay framework that describes delays in four phases was used: seeking, reaching, receiving, and remaining in care. We purposively recruited individuals with a history of TBI (n = 6) and 15 healthcare professionals working with persons with TBI (seven individuals representing each of the five facilities, the heads of neurosurgery and emergency medical services and eight additional healthcare providers who participated in the focus group discussions). Quantitative data were analysed descriptively while qualitative data were analysed thematically, following inductive and deductive approaches. FINDINGS: Five healthcare facilities (three community health centres, one district hospital and one tertiary hospital) were surveyed. We conducted 13 individual interviews (six with persons with TBI history, seven with healthcare providers from each of the five facilities, neurosurgery department and emergency medical service heads and two focus group discussions involving eight additional healthcare providers. Participants mentioned that alcohol abuse and high neighbourhood crime could lead to delays in seeking and reaching care. The most significant barriers reported were related to receiving definitive care, mostly due to a lack of diagnostic imaging at community health centres and the district hospital, delays in interfacility transfers due to ambulance delays and human and infrastructural limitations. A barrier to remaining in care was the lack of clear communication between persons with TBI and health facilities regarding follow-up care. CONCLUSION: Our study revealed that various individual-level, community and health system factors impacted TBI care. Efforts to improve TBI care and reduce injury-related morbidity and mortality must put in place more community-level security measures, institute alcohol regulatory policies, improve access to diagnostics and invest in hospital infrastructures.

Determining the Minimum Dataset for Surgical Patients in Africa: A Delphi Study.

BACKGROUND: It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry. METHODS: A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds). RESULTS: Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described. CONCLUSIONS: The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

Knowledge, attitude and perception towards lower limb amputation amongst persons living with diabetes in rural South Africa: A qualitative study.

BACKGROUND: South Africa has a high prevalence of diabetes mellitus (DM), a leading risk factor for lower limb amputation (LLA). Lower limb amputation is associated with significant morbidity and mortality. Lower limb amputation incidence can be mitigated through prompt identification and treatment of individuals at risk and engagement in self-management practices. Also, when LLA is inevitable, outcomes or prognosis can be improved with timely surgery. AIM: This study explored the knowledge, attitude and perception of persons living with diabetes towards LLA and its prevention. SETTING: Nqamakwe, a rural community in the Eastern Cape province of South Africa. METHOD: This was a descriptive, qualitative study involving persons living with DM, with and without LLA, and community leaders. Fifteen participants were recruited purposively and conveniently from a rural community in the Eastern Cape, South Africa. Data collection took place through semistructured interviews, in English and a local language, Xhosa. Interviews were transcribed and translated, and an inductive approach was used for thematic analysis. RESULTS: A total of 15 individual interviews were conducted. Of those, 13 were persons with DM, five with LLA, including one with bilateral LLA. There was a gap in knowledge on foot self-examination as a measure of preventing LLA amongst persons with DM. The attitude of persons without LLA was mostly fearful and their fears centred around perioperative death, risk for contralateral amputation, loss of limb and independence. Consent to LLA procedure was a last resort and only when pain levels were unbearable. Family support and information on rehabilitation services and assistive devices also fostered consent to LLA surgery. CONCLUSION: There is a need for awareness creation and adequate health education for persons living with DM on LLA and its prevention measures, especially foot care practices. Also, health education programmes for persons living with DM in rural areas should address the various misperceptions of LLA to reduce delays.Contribution: The article revealed gaps in knowledge on LLA and its prevention among individuals living with diabetes as well as areas of concerns that may potentially delay acceptance when LLA is inevitable. Findings from our study may assist primary health care providers to determine important issues to be addressed during routine and pre-operative patient education.

Colorectal Surgery Practice, Training, and Research in Low-Resource Settings.

Colorectal surgery (CRS) practice, training, and research differ between low- and middle-income countries (LMICs) and high-income countries due to disparity in resources. LMIC CRS is primarily done by general surgeons due to the paucity of fully trained colorectal surgeons. The majority of colon and rectal resections are done using open techniques, and laparoscopy and robotic platforms are only available in select private or academic centers. Multi-disciplinary teams are not available in most hospitals, so surgeons must have a broad knowledge base, and learn to adapt their practice. Formal CRS training opportunities through accredited post-residency fellowships and professional colorectal surgical associations are limited in LMICs. CRS is less established as an academic field, and less data are generated in LMICs. There are fewer staff and less dedicated funding for CRS research. However, LMIC colorectal surgeons and researchers can contribute valuable clinical findings especially on conditions of higher prevalence in their settings such as anal squamous cell carcinoma and obstetric fistulas. Effective surgical care for colorectal conditions requires significant investment in infrastructure, training, and governance in LMICs. This is critical to improve access to safe surgical care for all.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review.

Purpose of Review: Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings: A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager's four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public-private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary: Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information: The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop.

BACKGROUND: Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. OBJECTIVE: To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. METHODS: A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. RESULTS: Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. CONCLUSIONS: This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.

Referral of District Level Operations to Regional Hospitals in South Africa.

INTRODUCTION: In South Africa, district hospitals have limited surgical capacity, and most surgical conditions are referred to higher-level facilities for definitive management. This study aims to identify the proportion, type, and volume of district-level general surgery referrals to two regional government hospitals in South Africa. MATERIALS AND METHODS: This was a retrospective analysis of secondary data collected on persons who underwent general surgery operations at two South African regional hospitals between January 1, 2016 and December 31, 2018. District-level operations were those included in the South African Department of Health District Health Package. Descriptive analyses were performed to determine the proportions of district-level general surgery referrals and operations. Multivariate analyses were performed to determine factors associated with district-level general surgery operations. RESULTS: A total of 9357 persons underwent general surgery operations. Of these, 5925 (63.3%) were district-level operations. The most common district-level operations were lower limb amputations (n = 1007; 17.0%), abscess drainage (n = 936; 15.8 %), appendectomy (n = 791; 13.4%), non-trauma emergency laparotomy (n = 666; 11.2%), and inguinal hernia repair (n = 574; 9.7%). In multivariate analysis, district-level operations were associated with emergency conditions (OR: 5.64, P < 0.001), trauma (OR: 1.43, P < 0.001) and male gender (OR: 2.35, P < 0.001). CONCLUSIONS: In South Africa, the majority of general surgery diseases treated at regional hospitals are district-level conditions. The definition of district-level conditions could be too broad, and a narrower basket of surgical care for district hospitals would focus training efforts on achievable targets. More resources are needed at regional hospitals to care for their additional surgical burden.

Coverage of diabetes complications screening in rural Eastern Cape, South Africa: A cross-sectional survey.

BACKGROUND: There is a paucity of data on the coverage of diabetes mellitus (DM) complications screening in primary healthcare facilities in South Africa (SA). This study assesses the extent of screening for DM complications among individuals with type 2 DM attending primary health facilities in rural Eastern Cape (EC), SA. METHODS: The study adopted a descriptive, cross-sectional design and obtained data from 372 individuals with type 2 diabetes attending six selected primary healthcare centres (PHCs) in two EC districts. Demographic and clinical data were obtained through questionnaire-based interviews and reviews of medical records. We assessed the extent of screening for estimated glomerular filtration rate (eGFR), fasting lipogram, eye examination, foot examination and glycated hemoglobin (HbA1c) in the past year. RESULTS: Participants mean age was 62 (standard deviation [s.d.] ± 11) years, and their mean duration of diagnosis was 9 (s.d. ± 8) years. In the past year, HbA1c result was available for 71 (19.1%) of the participants; 60 (16.1%) had eGFR results, while only 33 (8.9%) had documented lipid results. In total, 52 (14.0%) had carried out eye examinations, while only 9 (2.3%) had undergone foot examinations in the past year. About two-thirds of the participants (59.9%) had not undergone any form of complication screening in the past year, and none had undergone the complete screening panel. CONCLUSION: The coverage of screening for DM complications was low across all indicators. Studies to understand barriers to and facilitators of DM complications screening at PHCs are required. Also, interventions to improve diabetes complication screening in the region are needed and should target the primary healthcare providers.

Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa.

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 ('Delays to receiving quality care'). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.

Telemedicine in Surgical Care in Low- and Middle-Income Countries: A Scoping Review.

BACKGROUND: Access to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking. AIM: To describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs. METHODS: This was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021. RESULTS: A total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes. CONCLUSION: Telemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes.

Lower limb amputations among individuals living with diabetes mellitus in low- and middle-income countries: A systematic review protocol.

BACKGROUND: The burden of diabetes mellitus (DM) and its associated complications continue to burgeon, particularly in low- and middle-income countries (LMICs). Lower limb amputation (LLA) is one of the most life-altering complications of DM, associated with significant morbidity, mortality and socio-economic impacts. High-income countries have reported a decreasing incidence of DM-associated LLA, but the situation in many LMICs is unknown. We aim to conduct a systematic review to determine the incidence and prevalence of DM-associated LLA in LMICs to better inform appropriate interventions and health system response. METHODS AND ANALYSIS: A systematic search of the literature will be conducted on five databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus and African Journal Online (AJOL). Only observational, quantitative studies reporting the incidence and/or prevalence of DM-related LLA will be considered. A validated study design-specific critical appraisal tool will be used to assess the risk of bias in individual studies. We will determine the incidence of LLA by examining the number of new cases of LLA among individuals with confirmed DM diagnosis during the specified period, while the prevalence will be based on the total number of all new and existing LLAs in a population. LLA will be considered as the resection of the lower limb from just above the knee to any point down to the toe. If heterogeneity is low to moderate, a random-effects meta-analysis will be conducted on extracted crude prevalence/incidence rates, with the median and interquartile range also reported. The systematic review will be performed in accordance with the JBI guideline for prevalence and incidence review. Study reporting will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline. PROSPERO REGISTRATION NUMBER: CRD42021238656.