hglobal-Index: A Novel Author-Level Measure of the Diffusion of Scientific Ideas Among High-, Low-, and Middle-Income Countries.

OBJECTIVE: To describe an intuitive and useful method for measuring the global impact of a medical scholar's research ideas by examining cross-border citations (CBCs) of peer-reviewed neurosurgical publications. METHODS: Publication and citation data for a random sample of the top 50 most academically productive neurosurgeons were obtained from Scopus Application Programming Interface. We characterized an author-level global impact index analogous to the widely used h-index, the hglobal-index, defined as the number of published peer-reviewed manuscripts with at least the same number of CBCs. To uncover socioeconomic insights, we explored the hglobal-index for high-, middle-, and low-income countries. RESULTS: The median (interquartile range) number of publications and CBCs were 144 (62-255) and 2704 (959-5325), respectively. The median (interquartile range) h-index and hglobal-index were 42 (23-61) and 32 (17-38), respectively. Compared with neurosurgeons in the random sample, the 3 global neurosurgeons had the highest hglobal-indices in low-income countries at 17, 13, and 9, despite below-average h-index scores of 33, 38, and 19, respectively. CONCLUSION: This intuitive update to the h-index uses CBCs to measure the global impact of scientific research. The hglobal-index may provide insight into global diffusion of medical ideas, which can be used for social science research, author self-assessment, and academic promotion.

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.

Evaluating the status of the Lancet Commission on Global Surgery indicators for India.

For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.

"Two Cultures in Favor of a Dying Patient": Experiences of Health Care Professionals Providing Snakebite Care to Indigenous Peoples in the Brazilian Amazon.

In the Brazilian Amazon, deaths and disabilities from snakebite envenomations (SBEs) are a major and neglected problem for the indigenous population. However, minimal research has been conducted on how indigenous peoples access and utilize the health system for snakebite treatment. A qualitative study was conducted to understand the experiences of health care professionals (HCPs) who provide biomedical care to indigenous peoples with SBEs in the Brazilian Amazon. Focus group discussions (FGDs) were carried out in the context of a three-day training session for HCPs who work for the Indigenous Health Care Subsystem. A total of 56 HCPs participated, 27 in Boa Vista and 29 in Manaus. Thematic analysis resulted in three key findings: Indigenous peoples are amenable to receiving antivenom but not to leaving their villages for hospitals; HCPs require antivenom and additional resources to improve patient care; and HCPs strongly recommend a joint, bicultural approach to SBE treatment. Decentralizing antivenom to local health units addresses the central barriers identified in this study (e.g., resistance to hospitals, transportation). The vast diversity of ethnicities in the Brazilian Amazon will be a challenge, and additional studies should be conducted regarding preparing HCPs to work in intercultural contexts.

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

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

Corticosteroid Randomization after Significant Head Injury and International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury Models Compared with a Machine Learning-Based Predictive Model from Tanzania.

Hospitals in low- and middle-income countries (LMICs) could benefit from decision support technologies to reduce time to triage, diagnosis, and surgery for patients with traumatic brain injury (TBI). Corticosteroid Randomization after Significant Head Injury (CRASH) and International Mission for Prognosis and Clinical Trials in Traumatic Brain Injury (IMPACT) are robust examples of TBI prognostic models, although they have yet to be validated in Sub-Saharan Africa (SSA). Moreover, machine learning and improved data quality in LMICs provide an opportunity to develop context-specific, and potentially more accurate, prognostic models. We aim to externally validate CRASH and IMPACT on our TBI registry and compare their performances to that of the locally derived model (from the Kilimanjaro Christian Medical Center [KCMC]). We developed a machine learning-based prognostic model from a TBI registry collected at a regional referral hospital in Moshi, Tanzania. We also used the core CRASH and IMPACT online risk calculators to generate risk scores for each patient. We compared the discrimination (area under the curve [AUC]) and calibration before and after Platt scaling (Brier, Hosmer-Lemeshow Test, and calibration plots) for CRASH, IMPACT, and the KCMC model. The outcome of interest was unfavorable in-hospital outcome defined as a Glasgow Outcome Scale score of 1-3. There were 2972 patients included in the TBI registry, of whom 11% had an unfavorable outcome. The AUCs for the KCMC model, CRASH, and IMPACT were 0.919, 0.876, and 0.821, respectively. Prior to Platt scaling, CRASH was the best calibrated model (χ2 = 68.1) followed by IMPACT (χ2 = 380.9) and KCMC (χ2 = 1025.6). We provide the first SSA validation of the core CRASH and IMPACT models. The KCMC model had better discrimination than either of these. CRASH had the best calibration, although all model predictions could be successfully calibrated. The top performing models, KCMC and CRASH, were both developed using LMIC data, suggesting that locally derived models may outperform imported ones from different contexts of care. Further work is needed to externally validate the KCMC model.

Emergency Care Gap in Brazil: Geographical Accessibility as a Proxy of Response Capacity to Tackle COVID-19.

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.

The Impact of Violence on the Anxiety Levels of Healthcare Personnel During the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic stressed the importance of healthcare personnel. However, there is evidence of an increase in violence against them, which brings consequences, such as anxiety. The aim of this study was to analyze the anxiety levels of health professionals who have or not suffered violence during the COVID-19 pandemic, and verify the variables associated with the risk of starting to take medication for anxiety. Methods: We assessed the anxiety profile of health professionals in Brazil through an online questionnaire, using the Generalized Anxiety Disorder 7-item Scale (GAD-7), in relation to groups of participants who have or not suffered violence during the COVID-19 pandemic. We used Cronbach's alpha reliability coefficient to check the consistency of the responses, and the effect size using the r coefficient. Principal Component Analysis was used to verify the differences in anxiety scores between the two groups. Logistic regression analysis was also used to verify the variables associated with the risk of starting medication for anxiety and considered statistically significant when p < 0.05. Results: A total of 1,166 health professionals participated in the study, in which 34.13% had a normal anxiety profile, 40.14% mild, 15.78% moderate, and 9.95% severe. The mean score of the sum of the GAD-7 was 7.03 (SD 5.20). The group that suffered violence had a higher mean (8.40; SD 5.42) compared to the group that did not (5.70; SD 4.60). In addition, the median between both groups was significantly different (7.0 vs. 5.0; p < 0.01). Approximately 18.70% of the participants reported having started taking medication to treat anxiety during the pandemic. The factors that increased the chances of these professionals starting medication for anxiety p < 0.05 were having suffered violence during the pandemic (OR 1.97; 95% CI 1.42-2.77), being nurses (OR 1.61; 95% CI 1.04-2.47) or other types of health professionals (OR 1.58; 95% CI 1.04-2.38), and having a mild (OR 2.11; 95% CI 1.37-3.34), moderate (OR 4.05; 95% CI 2.48-6.71) or severe (OR 9.08; 95% CI 5.39-15.6) anxiety level. Conclusion: Brazilian healthcare professionals who have suffered violence during the pandemic have higher anxiety scores and higher risk to start taking anxiety medication.

Smart Check - COVID-19 triage system: Evaluation of the impact on the screening time and identification of clinical manifestations of SARS-CoV-2 infection in a public health service.

INTRODUCTION: Most patients with COVID-19 have mild or moderate manifestations; however, there is a wide spectrum of clinical presentations and even more severe repercussions that require high diagnostic suspicion. Vital sign acquisition and monitoring are crucial for detecting and responding to patients with COVID-19. OBJECTIVE: Thus, we conducted this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID-19 and to identify the main initial clinical manifestations in these patients. METHODOLOGY: We assessed triage times before and after the use of Smart Check in 11 466 patients at Hospital Nossa Senhora da Conceição in Porto Alegre, Brazil, from 1 June to 31 July 2020. In this group, we identified 220 patients for the identification of COVID-19 clinical manifestations in a case-control analysis. RESULTS: Smart Check was able to decrease the triage time by 33 seconds on average (P < .001), with 75% of the exams being performed within 5 minutes, whereas with the usual protocol these steps were performed within 6 minutes. A range of clinical presentations made up the COVID-19 initial manifestations. Those with the highest frequency were dry cough (46.4%), fever (41.3%), dyspnoea (35.8%), and headache (31.8%). Loss of appetite was the manifestation that had a statistically significant association with the SARS-CoV-2 presence (univariate analysis). When analysed together, loss of appetite associated with dyspnoea and/or ageusia and/or fever was related to the diagnosis of COVID-19. CONCLUSIONS: Smart Check, a simple clinical evaluation tool, along with the targeted use of rapid PCR testing, can optimise triage time for patients with and without COVID-19. In triage centres, a number of initial signs and symptoms should be cause for SARS-CoV-2 infection suspicion, in particular the association of respiratory, neurological, and gastrointestinal manifestations.

Parâmetros psicométricos da Prosocial and Antisocial Behavior Sport Scale (PABSS) para o contexto brasileiro / Parámetros psicométricos de la Prosocial and Antisocial Behavior Sport Scale (PABSS) para el contexto brasileño / Prosocial and Antisocial Behavior Sport Scale (PABSS) in Brazil Psychometric parameters of the Prosocial and Antisocial Behavior Sport Scale (PABSS) for the Brazilian context

Resumo Contar com uma medida psicometricamente adequada para a avaliação dos comportamentos moralmente relevantes de atletas é importante para fomentar pesquisas e viabilizar estratégias de intervenção eficazes. O objetivo da presente pesquisa foi estimar propriedades psicométricas da Prosocial and Antisocial Behavior Sport Scale (PABSS) para o contexto brasileiro. A amostra foi composta por 360 atletas de ambos os sexos (idade média 16.1 ± 3.61; 64.7 % homens). A análise fatorial exploratória indicou a pertinência da estrutura composta por quatro fatores: (1) comportamento pró-social direcionado aos companheiros de equipe (CPC); (2) comportamento pró-social direcionado aos adversários (CPA); (3) comportamento antissocial direcionado aos companheiros de equipe (CAC); (4) comportamento antissocial direcionado aos adversários (CAA), explicando conjuntamente 66.1 % da variância total, o que corrobora a hipótese teórica. Adicionalmente, a análise fatorial semiconfirmatória apresentou comprovação do modelo composto por quatro fatores: [(X1 = 126.685, gl = 116. p = .234; X2/gl = 1.09; CFI = 0.998 (IC 95 % = 0.997-0.999); GFI = 0.991 (IC 95 % = 0.997- 0.999); RMSEA = 0.018 (IC 95 °% = 0.016-0.020)]. Todos os fatores apresentaram índices desejáveis de consistência interna, alfa de Cronbach superiores a .78 e ômega de Mcdonald superiores a .88. Também foram observadas as associações entre comportamento moral e valores no esporte. Conclui-se que a versão brasileira da PABSS reúne evidências psicométricas adequadas, podendo ser utilizada em estudos futuros.

Resumen Contar con una medida psicométrica apropiada para evaluar los comportamientos moralmente relevantes de los atletas es importante para fomentar la investigación y permitir estrategias de intervención efectivas. El objetivo de esta investigación fue estimar las propiedades psicométricas de la Prosocial and Antisocial Behavior Sport Scale (PABSS) para el contexto brasileño. La muestra consistió en 360 atletas de ambos sexos (promedio de edad 16.1 ± 3.61; 64.7 % hombres). El análisis factorial exploratorio indicó la relevancia de la estructura que consta de cuatro factores: (1) Comportamiento prosocial dirigido a compañeros de equipo (CPC); (2) Comportamiento prosocial dirigido a oponentes (CPA); (3) Comportamiento antisocial dirigido a compañeros de equipo (CAC); (4) Comportamiento antisocial dirigido a oponentes (CAA), explicando conjuntamente el 66.1 % de la varianza total, lo que corrobora la hipótesis teórica. Además, el análisis factorial semiconfirmatorio mostró pruebas del modelo compuesto por cuatro factores: [(X2 = 126.685, gl = 116, p = .234; X2/gl = 1.09; CFI = 0.99 (IC 95% = 0.997-0.999); GFI = 0.99 (IC 95 % = 0.997-0.999); RMSEA = 0.018 (IC 95 % = 0.016-0.020)]. Todos los factores tenían índices de consistencia interna alfa de Cronbach deseables mayores a 0.78 y omega de McDonald mayores a 0.88. También se observaron asociaciones entre el comportamiento moral y los valores en el deporte. En conclusión, la versión brasileña del PABSS reúne evidencia psicométrica adecuada y puede ser utilizada en futuros estudios.

Abstract Having an appropriate psychometric measure for assessing the morally relevant behaviors of athletes is important to encourage research and enable effective intervention strategies. The aim of this research was to verify the psychometric properties of the Prosocial and Antisocial Behaviors Sport Scale (PABSS) for the Brazilian context. The sample consisted of 360 athletes of both sexes (average age 16.1±3.61; 64.7% men). The exploratory factorial analysis indicated the adequacy of the structure comprising four factors: 1) Prosocial behavior directed to teammates (CPC) 2) Prosocial behavior directed to opponents (CPA); (3) Anti-social behavior directed to teammates (CAC); (4) Anti-social behavior directed to opponents (CAA), which jointly explains 66.1% of the total variance, thus corroborating the theoretical hypothesis. In addition, Semi-confirmatory Factor Analysis showed evidence of the four-factor model: [(X2= 126.685, gl= 116, p = .234; X2/gl= 1.09; CFI= 0.99 (IC 95%= 0.997-0.999); GFI= 0.99 (IC 95% = 0.997- 0.999); RMSEA= 0.018 (IC 95%= 0.016-0.020)]. All factors had desirable internal consistency indexes of Cronbach's alpha greater than 0.78 and McDonald's Omega greater than 0.80. Associations between moral behavior and values in sports were also observed. In conclusion, the Brazilian version of the PABSS presented adequate psychometric evidence and can be used in future studies.

Influence of the global crisis of 2008 and the brazilian political oscillations of 2014 on suicide rates: An analysis of the period from 2002 to 2017.

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.

Alcohol-Related Risky Behavior Patterns and Their Association With Alcohol Use and Perceived Alcohol Stigma in Moshi, Tanzania.

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.

Alcohol Availability, Cost, Age of First Drink, and Its Association with At-Risk Alcohol Use in Moshi, Tanzania.

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.

Validity, Reliability, and Diagnostic Cut-off of the Kinyarwandan Version of the Hamilton Depression Rating Scale in Rwanda.

Introduction: In Rwanda, major depressive disorder affects 11.9% of the population and up to 35% of genocide survivors. Mental health services remain underutilized due to stigma and lack of awareness. Increasing the ability and capacity to diagnose and treat mental disorders is considered important to close this gap. We describe the translation, validity, and reliability assessment of the Hamilton Depression Rating Scale (HDRS) as a diagnostic tool for moderate to severe depression in Rwanda. Methods: The HDRS-21 was translated by a multi-group taskforce. We validated the translation against expert assessment in a comparative study on a sample of patients living with depression and of healthy volunteers. Psychometric properties, namely internal structure, reliability, and external validity were assessed using confirmatory factor analysis, three reliability calculations, and correlation analysis, respectively. Maximized Youden's index was used for determining diagnostic cut-off. Results: The translated version demonstrated a kappa of 0.93. We enrolled 105 healthy volunteers and 105 patients with confirmed mild to severe depression. In the confirmatory factor analysis, HDRS had good factor loadings of 0.32-0.80. Reliability coefficients above 0.92 indicated strong internal consistency. External validity was shown by good sensitivity (0.95) and specificity (0.94) to differentiate depression from absence of depression. At a cut-off point of 17 for the diagnosis of depression, sensitivity and specificity were both 0.95 relative to gold standard. Conclusion: The validated HDRS in Kinyarwanda with diagnostic cut-off provides mental healthcare staff with an accurate tool to diagnose moderate to severe depression, enabling closure of the diagnosis and treatment gap.

An Attitude Survey and Assessment of the Feasibility, Acceptability, and Usability of a Traumatic Brain Injury Decision Support Tool in Uganda.

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.

Alcohol stigma as it relates to drinking behaviors and perceptions of drink drivers: A mixed method study in Moshi, Tanzania.

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.

Estimating prognosis for traumatic brain injury patients in a low-resource setting: how do providers compare to the CRASH risk calculator?

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.

Road traffic crash experience among commercial motorcyclists in Kigali, Rwanda.

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.

Perceptions of alcohol use among injury patients and their family members in Tanzanian society.

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.