Browsing by Author "Haglund, Micheal M"

Introduction: Traumatic brain injury (TBI) accounts for the majority of Uganda’s neurosurgical disease burden, but invasive intracranial pressure (ICP) monitoring is infrequently used. Noninvasive monitoring through tools like pupillometry could change the care of TBI patients in such a setting. Given the novelty of noninvasive monitoring in Uganda, this study sought to assess the feasibility of pupillometry for noninvasive ICP monitoring for TBI patients. Methods: Healthcare workers in Kampala, Uganda received education on pupillometry, practiced using the device on healthy volunteers, and completed interviews focused on pupillometry and its potential implementation. Qualitative analysis of the interviews assessed pupillometry acceptability and feasibility. Quantitative analysis assessed learning time, time to obtain a measurement, and accuracy of measurements during training. Results: Twenty-two providers completed the study. Participants described how pupillometry would add value to the care of patients with TBI during examination, delivering interventions, and monitoring. Reported concerns included the cost, understanding, and maintenance needs of the pupillometer. Participants also discussed potential challenges with using pupillometry, including limited accessibility and availability as well as challenges with documentation. They suggested offering continued education and providing technical support as strategies to support successful implementation. During training, average time to learn was 13.6 minutes (IQR 3.8) and average time to obtain a measurement was 51.1 seconds (IQR 14.2). Paired t tests to evaluate accuracy after training showed no statistically significant difference in the comparison measurements. Conclusion: Pupillometry would be feasible to use for noninvasive ICP monitoring for TBI patients in Uganda, as long as concerns about the device could be addressed and implementation barriers overcome.

Background. The confluence of a capacity-exceeding disease burden and persistent resource shortages have resulted in traumatic brain injury’s (TBI) devastating impact in low and middle income countries (LMIC). Lifesaving care for TBI depends on accurate and timely decision making within the hospital. As result of technology and highly skilled provider shortages, treatment delays are common in low resource settings. This reality demands a low cost, scalable and accurate alternative to support decision making. Decision support tools leveraging the accuracy of modern prognostic modeling techniques represents one possible solution. This thesis is a collation of research dedicated to the advancement of TBI decision support technology in low resource settings. Methods. The study location included three national and referral hospitals in Uganda and Tanzania. We performed a survival analysis, externally validated existing TBI prognostic models, developed our own prognostic model, and performed a feasibility study for TBI decision support tools in an LMIC. Results. The survival analysis revealed a greater surgical benefit for mild and moderate head injuries compared to severe injuries. However, severe injury patients experienced a higher surgery rate than mild and moderate injuries. We developed a prognostic model using machine learning with a good level of accuracy. This model outperformed existing TBI models in regards to discrimination but not calibration. Our feasibility study captured the need for improved prognostication of TBI patients in the hospital. Conclusions. This pioneering work has provided a foundation for further investigation and implementation of TBI decision support technologies in low resource settings.

Neurosurgical and neurological conditions account for a significant disease burden worldwide, with low- and middle-income countries bearing more than 90% of the burden. Uganda is a low-income nation with a high demand for neuro care services but limited access, especially in rural and remote areas. Mobile health clinics, which have proven to be effective in other specialties, could be adapted to provide neurological care in such regions. The objective of this research was to establish the feasibility, appropriateness, and usability of mobile neuro clinics for providing neurological care to people in Uganda's rural and remote communities. Participants who met the inclusion criteria were invited to participate in an education session. Following the education session, the participants participated in an interview session to evaluate the feasibility, appropriateness, and usability of mobile neuro clinics. The education and interview tools were developed using the Consolidated Framework for Implementation Research (CFIR). To weight provider views, a sentiment weighted scale was used, with total aggregate sentiment scores greater than 42 in each CFIR domain indicating high feasibility, acceptability, and usability. All the assessed CFIR domains scored above sentiment score of 49. The implementation process domain (167) received the best overall sentiment score, followed by the implementation climate structure (141), inner setting domain (102), innovation domain (59), and outer setting domain (55). According to the findings of the research, mobile neuro clinics are feasible, appropriate, and usable in Uganda. To achieve the best results, however, careful planning and integration involving stakeholders from conceptualization to execution are required.

Background: Epilepsy is one of the most common neurological disorders globally, and an overwhelmingly high number of people who suffer from epilepsy reside in low- and middle-income countries (LMICs), where access to care is a significant challenge. Stigma associated with epilepsy and poor knowledge of the disease further hamper access to appropriate care. According to the World Health Organization (WHO) treatment guidelines, epilepsy can be treated cost-effectively in low-resource settings. However, in many LMIC settings, capacity for epilepsy treatment is inadequate. In Uganda specifically, there is a significant treatment gap in epilepsy care, and the magnitude of and reasons for this gap are not well characterized. In addition to suffering caused by disease in people with epilepsy (PWE), there are severe social ramifications of disease due to stigma. Therefore, access to adequate treatment is imperative for PWE in Uganda.

Purpose: The general objective of the overall project is to characterize epilepsy treatment and patient outcomes in public hospital-based care in Uganda, specifically in Mulago National Referral Hospital (MNRH), Butabika National Mental Hospital (BNMH), and Mbarara Regional Referral Hospital (MRRH). Outcomes from this study can inform specific targets of future interventions, and can provide insight towards improving the provision of epilepsy care in Uganda. The present thesis focuses on a narrower objective of the overall project, and involves validating outcome measures for PWE in Uganda, as well as using these measures in a preliminary analysis to identify predictors that most influence health outcomes.

Methods: The present study is nested in a larger prospective cohort study that recruits patients of all ages seeking care for epilepsy at MNRH, BNMH, and MRRH, and conducts follow-up over the phone at three weeks, three months and six months. At the hospital baseline visit, patients and/or caregivers were interviewed in either English, Luganda, or Runyankole to obtain demographic and clinical information and the Personal Impact of Epilepsy Scale (PIES), among other measures conducted as a part of a longer one- to two-hour interview. Reliability, internal consistency specifically, was assessed using three parameters: Cronbach’s alpha, McDonald’s Omega, and composite reliability for the PIES. Construct validity (internal structure) was evaluated with principal components analysis (PCA) and confirmatory factor analysis (CFA). Based on the validation results, the PIES questionnaire was treated as three outcome measures, from three subscales of the PIES. Possible predictors of the subscale scores were assessed using bivariate and multivariable linear regression.

Results: 626 patients seeking care for epilepsy and/or their caregivers were interviewed at baseline. The three-factor model of the PIES had excellent reliability. The PCA and CFA models for the scale demonstrated adequate fit with the TLI, CFI and RMSEA indices, but the model demonstrated inadequate fit with the Chi-square indicator. Several demographic and clinical indicators were associated with the three subscale scores of the PIES, Seizures, Adverse Effects of Medications, and Mood and Social Situation, in the multivariable regression models. Of these indicators, for the PIES Seizures Subscale Score, recruitment site and experience of confusion or tiredness after seizures were negatively associated with outcome scores, while taking one anti-epileptic drug (AED), education, and employment were positively associated with outcome scores. For the PIES Adverse Effects of Medications Subscale Score, taking AEDs, recruitment at MRRH, experience of isolated repetitive movements, auras, learning difficulties, and fevers were negatively associated with outcome scores, while employment status was positively associated with outcome scores. Finally, for the PIES Mood and Social Situation Subscale, recruitment at MRRH, experience of confusion and tiredness after seizures, learning difficulties, and phenytoin use were negatively associated with outcome scores, while education and employment were positively associated with outcome scores.

Conclusions: This thesis presents the first Luganda and Runyankole versions of the PIES, and the first validation of this scale with epilepsy patients in Uganda. The PIES has demonstrated adequate reliability and validity, and can be used to assess epilepsy related health outcomes, which is especially important in low-resource settings, where diagnostic equipment and specialist providers for epilepsy are not readily accessible. Furthermore, this thesis presents some preliminary results from the overall cohort study that use the PIES scale to identify some potential predictors of epilepsy-related health outcomes. Among the variables that showed associations with the PIES subscale scores, education and employment were associated with all three scores, highlighting the importance of community- and policy-based interventions for PWE, in addition to the possible identification of epilepsy subpopulations that may be at higher risk for poorer outcomes during clinical interventions.

Background: Private healthcare resources, which include private health insurance agencies, households, facility-based NGOs and private firms cover over 75% of the health expenditure in Uganda. Uganda’s National Health Accounts for the financial year 2009/2010 reported higher spending from private sources than public sources. Further results showed out of pocket expenditure from households was the largest source of funding, contributing 40% to 46% of total health expenditure. The expenditure of a large fraction of household income on health care results in financial risk for most Ugandans and often leaves families impoverished. Therefore, the goal of this study is to describe in detail the burden of cost of patients, using neurosurgery as a proxy. Methods: The study was carried out in Mulago Hospital, Kampala, Uganda. Eligible patients were patients between the ages of 18-90 years of age who had undergone a neurosurgical procedure at Mulago and were on the neurosurgery ward post-surgery. Ultimately, 144 patients agreed to be part of the study. These patients were recruited three nurses who worked on the neurosurgery ward. The data were collected via the use of questionnaires to interview the patients and/or caregivers. We defined catastrophic expenditure as 10% of the household income, while impoverishment was defined as patients living on less than $1 a day. Our analysis was mainly descriptive; however, we ran several regressions to determine predictors of catastrophic expenditure, and impoverishment. Results: 59% of the patients are living below the poverty line. An additional 12% were impoverished by expenditure on healthcare. 93% of the patients experienced financial catastrophe due to the direct costs they incurred in seeking care at the hospital. The patients pay, on average, 27% of the hospital costs incurred in treating the patients. Conclusions: The majority of the patients in our study experienced financial catastrophe in seeking neurosurgical care. Furthermore, most of the patients who sought surgical care were already impoverished. These data underscore the fact that the costs associated with accessing neurosurgical care at Mulago Hospital often result financial hardship on the patients, despite the fact that care in Mulago Hospital is supposed to be free.

Background: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the quality of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala Uganda.

Methods: We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.

Results: 563 TBI patients were enrolled from 1 June – 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category (mild, moderate, severe GCS 6-8, severe GCS 3-5), mortality differed by management pathway. The variables predictive of mortality were: moderate to severe TBI (GCS 9-12, GCS 6-8, and GCS 3-5), more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.

Conclusions: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Despite significant potential for informing and driving global neurosurgery research and clinical efforts, there are significant barriers to obtaining high quality, interoperable neurosurgical data in LMICs. The aim of this paper was to initiate development of a simple, reproducible framework to guide prospective database implementation. We adapted existing established frameworks to the global neurosurgery research context and then used a case study to assess how well the framework anticipated quality issues. The proposed framework encompasses domains and key facilitators to producing high quality, interoperable neurosurgical data in low-resource settings. Future studies are needed to evaluate and further refine this framework.

Background/ObjectivesAfrica has only 1% of the global neurosurgery workforce, despite having 14% of the global population and 15% of the global neurosurgical disease burden. Also, neurosurgical training is hampered by paucity of training institutions, dearth of training faculty, and deficiency of optimal training resources. The study appraises the current specialist neurosurgical workforce in Africa, evaluates the major neurosurgery training programs, and projects the 2030 workforce capacity using current growth trends. Methods The study involved systematic and gray literature search, with quantitative analysis of retrospective data on the neurosurgery workforce, qualitative evaluation of the major neurosurgery training programs for their strength, weaknesses, opportunities, and threats, and projection modeling of the workforce capacity up to year 2030. Results 1,974 neurosurgeons serve 1.3 billion people (density 0.15/100,000; ratio 1:678,740), in Africa, with the majority (1,271; 64.39%) in North Africa. There are 106 specialist neurosurgery training institutions in 26 African countries, with North Africa having 52 (49.05%) of the training centers. Training is heterogenous, with the major programs being the West African College of Surgeons (WACS) - 24 centers across 7 countries, and the College of Surgeons of East, Central and Southern Africa (COSECSA) - 17 centers in 8 countries. At the current linear growth rate of 74.2 neurosurgeons/year or exponential growth rate of 6.81% per annum, Africa will have 2,716 - 3,813 neurosurgeons by 2030, with a deficit of 4,795 - 11,953 neurosurgeons. The continent requires a scale-up of its linear growth rate to 663.4 - 1269.5 neurosurgeons/year, or exponential growth rate to 15.87% - 22.21% per annum to meet its needs. While North African countries will likely meet their 2030 workforce requirements, sub-Saharan African countries will have significant workforce deficits. Conclusion Despite a recent surge in neurosurgery residency training, the current state of Africa’s neurosurgery workforce is dire, and many countries will be unable to meet their workforce requirements by 2030 at current growth trends. A significant scale-up of the neurosurgery workforce is required in order to meet these targets.

Background

Epilepsy is a chronic neurological disorder characterized by recurrent seizure activity caused by abnormal electrical activity in the brain. Over 80% of all cases globally occur in Low- and Middle-Income countries. A high treatment gap exists in LMICs, including Uganda, with 80% of people with epilepsy never receiving treatment. Studies have shown that even with existing medical services, a lack of skilled workforce, medication stock-outs, and long distances to health facilities contribute to the high treatment gap. This study describes the capacity, distribution of health facilities, and referral patterns between facilities that care for epilepsy patients in Uganda.

Methods

We conducted a cross-sectional survey adapted from the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. It was modified to include WHO Mental Health Gap Action Program (mhGAP) resources for epilepsy and the Tool for Situational Analysis to Assess Epilepsy Care. Data collection occurred between July and August 2022. Our sample included all regional and general hospitals and a sample of randomly selected Health Centers in Southwestern Uganda. We used probability proportional to size sampling to determine which Health Centers to include in our sample. We had only public health facilities in our sample. Data were collected through in-person interviews conducted by trained research assistants. A three-tiered categorical score (full, intermediate, and low capacity) was used to describe epilepsy capacity. For scoring, hospitals were stratified into three groups/facility levels: tertiary care (regional referral hospitals), secondary care (district hospitals/health center IVs), and primary care (health center IIIs), as we hypothesized that available resources would differ between the groups. We did geospatial mapping to show the distribution of facilities.

Ethical approval was obtained from the Makerere School of Public Health Research Ethics Committee (Protocol 1104), the Uganda National Council of Science and Technology (Protocol HS2344ES), and Duke University’s Institutional Review Board (Protocol 00110747).

Results63 facilities were surveyed, with 100% completion in all facilities. 63 (100%) facilities provide care for epilepsy patients. None of the facilities surveyed had full capacity to treat epilepsy patients. Most of our sampled facilities had a low capacity to treat epilepsy: 100% of tertiary care facilities, 77.3% of secondary care facilities, and 83.8% of primary care facilities. Overall capacity was weakest in medication, equipment, and human resources and highest in infrastructure and guidelines. Conclusion While epilepsy services are present in Uganda’s southwestern region, a lack of vital medicines, staff shortages, and technology can limit service delivery. Task shifting and sharing have been widely implemented to address workforce shortages. The findings of this study can help inform policy to improve service delivery for epilepsy patients.

Background: Barriers to surgical care in low- and middle-income countries have basis in theoretical frameworks, but are often left undefined and understudied. Based on the Access Evaluation Framework and Healthcare Barrier Model, this study implemented two consumer decision tools and a qualitative interview to elucidate significant barriers to seeking surgical care in Uganda.

Methods: Participants were recruited from a convenience sample within the surgical wards of one national referral hospital and one regional referral hospital in Uganda. Individuals selected for the study answered a brief questionnaire and a ranking and rating exercise followed by an in-depth semi-structured interview. The questionnaire evaluated demographic, economic, transportation, and care-seeking characteristics, while the ranking and rating exercises assessed potential barriers to surgical care. Descriptive statistics were used to assess characteristics of the sample. Ranking and rating medians were compared between the two exercises for each barrier.

Results: Among the 214 participants, cost of surgery, distance to hospital, and transportation to hospital were identified as the most significant barriers to care. Language barrier, no control over decision making, and no caretaker available at the hospital were identified as the least significant barriers to care. Mulago National Referral Hospital had significantly greater costs and transportation times indicating larger scale barriers to care than Jinja Regional Referral Hospital even though top barriers were similar.

Conclusions: Both the ranking and rating exercises and interviews indicated that cost was the most significant barrier to surgical care among care-seekers in Uganda. Transportation to the hospital and distance from the hospital remain large barriers that need to be considered as well. These complementary analysis tools provide evidence that future policies and research need to consider mitigating cost, distance, and transportation issues for patients that need a surgical intervention. Next steps in determining more granular level differences between barriers will help understand how best to address these issues.

Background: In sub-Saharan Africa, epilepsy is ranked 14th for the highest disability burden. In Uganda, specifically, epilepsy has risen from 14th in 2007 to 10th for the highest burden of disability in 2017. Despite the significant disease burden of epilepsy in Uganda, there have been no national prevalence studies. Our first aim is to understand the overall epilepsy prevalence in Uganda. Additionally, we want to understand the impact that demographic and socio-economic factors have on epilepsy prevalence and whether these factors varied in their impact geographically.

Methods: Three hundred and thirty EAs were selected for this study, stratifications included urban/rural and the 10 sub-regions delineated in the DHS. In each EA, we randomly selected 30 households out of 100 (on average). All members of the household that consented, or assented, to be part of the study were included. We used a 13-item survey, broken into two levels, to screen for epilepsy and collected a variety of demographic and socio-economic factors from each participant. These factors were mapped to determine the impact, and significance, that each factor had on the geographic distribution of epilepsy prevalence in Uganda.

Results: The groups who had the highest epilepsy prevalence were under 35 years of age, had less than a primary level of education, lived in rural areas, had less than five household members, had access to a mobile phone and had less than two combined assets. The vast majority of positive screened participants were Christian and made less than 20,000 UGX a week.

Conclusions: From this study, we can see areas within Uganda where some geographic, demographic, and socio-economic factors have possibly played a role in epilepsy prevalence, as defined by our first screen. We can begin to understand these patterns and explore them further to determine the true nature of these factors and their relationship with epilepsy. There are current policy changes that could greatly improve access to care, stigma, and prevent further epilepsy cases by improving infrastructure in key areas.

Background: Since 2007, there has been an ongoing collaboration between Duke University and Mulago National Referral Hospital (NRH) in Kampala, Uganda to increase surgical capacity. This program is prepared to expand to other sites within Uganda to improve neurosurgery outside of Kampala as well. This study assessed the existing progress at Mulago NRH and the neurosurgical needs and assets at two potential sites for expansion. Methods: Three public hospitals were visited to assess needs and assets: Mulago NRH, Mbarara Regional Referral Hospital (RRH), and Gulu RRH. At each site, a surgical capacity tool was administered and healthcare workers were interviewed about perceived needs and assets. A total of 39 interviews were conducted between the three sites. Thematic analysis of the interviews was conducted to identify the reported needs and assets at each hospital. Results: Some improvements are needed to the Duke-Mulago Collaboration model prior to expansion; minor changes to the neurosurgery residency program as well as the method for supply donation and training provided during neurosurgery camps need to examined. Neurosurgery can be implemented at Mbarara RRH currently but the hospital needs a biomedical equipment technician on staff immediately. Gulu RRH is not well positioned for Neurosurgery until there is a CT Scanner somewhere in the Northern Region of Uganda or at the hospital. Conclusions: Neurosurgery is already present in Uganda on a small scale and needs rapid expansion to meet patient needs. This progression is possible with prudent allocation of resources on strategic equipment purchases, human resources including clinical staff and biomedical staff, and changes to the supply chain management system.

Duke University Medical Center neurosurgeon, Dr. Micheal Haglund, established a twinning program between Duke and Mulago Hospital in Kampala, Uganda back in 2008. While a study was performed in 2011 that showed that the program had increased neurosurgical capacity, there was no study looking at patient outcomes. This study was thus undertaken to explore patient outcomes in an effort to provide information the program could use for evaluating its impact.

This study was carried out in a retrospective fashion including all patients who underwent a neurosurgical procedure at Mulago Hospital from fiscal year 2005 to 2013. Data for this study was extracted from three sources: surgical log books, patient charts, and Mulago Hospital death registry. Information from these sources were collected using electronic data collection tools to determine morality rate (30-day and overall), infection rate (pre-op and post-op), and length of stay (total, pre-op, and post-op). These three outcome measures were then compared pre-program versus post-program.

Peri-operative mortality rate (POMR), or 30-day mortality, was significantly increased from 7.41% pre-program to 13.62% post-program. Overall mortality was also significantly increased from 12.96% pre-program to 19.89% post-program. Relative risk for POMR was 1.85 (1.13, 3.03) and overall mortality was 1.53 (1.06, 2.22). Pre-op infection was significantly decreased from 29.74% pre-program to 22.1% post-program with a relative risk of 0.75 (0.56, 1.00). Mean total length of stay and pre-operative length of stay were both significantly decreased.

The results show that the program has had a generally positive impact, but the mortality increase is an important question to explore. This result may be attributed to complexity and triaging issues, but a prospective analysis would be the only way to make that determination. Additionally, further qualitative and deeper quantitative investigations can provide a fuller evaluation of the program's impact. Overall it is clear that this program is allowing greater access to neurosurgical care to a population that would have otherwise went without care.

Background:

Knowing the scope of neurosurgical disease at Mbarara Hospital is critical for infrastructure planning, education and training. In this study, we aim to evaluate the neurosurgical outcomes and identify predictors of mortality in order to potentiate platforms for more effective interventions and inform future research efforts at Mbarara Hospital.

Methods:

This is retrospective chart review including patients of all ages with a neurosurgical disease or injury presenting to Mbarara Regional Referral Hospital (MRRH) between January 2012 to September 2015. Descriptive statistics were presented. A univariate analysis was used to obtain the odds ratios of mortality and 95% confidence intervals. Predictors of mortality were determined using multivariate logistic regression model.

Results:

A total of 1876 charts were reviewed. Of these, 1854 (had complete data and were?) were included in the analysis. The overall mortality rate was 12.75%; the mortality rates among all persons who underwent a neurosurgical procedure was 9.72%, and was 13.68% among those who did not undergo a neurosurgical procedure. Over 50% of patients were between 19 and 40 years old and the majority of were males (76.10%). The overall median length of stay was 5 days. Of all neurosurgical admissions, 87% were trauma patients. In comparison to mild head injury, closed head injury and intracranial hematoma patients were 5 (95% CI: 3.77, 8.26) and 2.5 times (95% CI: 1.64,3.98) more likely to die respectively. Procedure and diagnostic imaging were independent negative predictors of mortality (P <0.05). While age, ICU admission, admission GCS were positive predictors of mortality (P <0.05).

Conclusions:

The majority of hospital admissions were TBI patients, with RTIs being the most common mechanism of injury. Age, ICU admission, admission GCS, diagnostic imaging and undergoing surgery were independent predictors of mortality. Going forward, further exploration of patient characteristics is necessary to fully describe mortality outcomes and implement resource appropriate interventions that ultimately improve morbidity and mortality.

Background Globally, it is estimated that 11% of all disability adjusted life years lost result from conditions requiring surgical intervention. Efforts to estimate burden at country-specific levels have been recommended to plan surgical delivery platforms. However, existing analyses of hospital records are not representative of population-level needs. Therefore, we piloted a population-level epidemiologic survey in a large, peri-urban District of Uganda. The exercise would inform implementation of the eventual nation-wide survey of Uganda.

Methods A 2-stage cluster sampling design was used to sample fifty five (55) households. In each household, up to 2 individual respondents were recruited. Village Health Team (VHT) members served as enumerators and used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument to acquire self-reported data on existing surgical conditions and surgical history. A head/representative of household was asked about household deaths within the previous 12-months. Descriptive statistics, weighted adjustments, and regression modeling were used to analyze results.

Results Six of 96 individual respondents (6.25%) reported an existing surgical condition. The lifetime prevalence of surgical conditions was 26.0% (25 of 96 individuals), reporting 33 total surgical conditions. The most commonly reported problems were wound related (54.5% - 18 of 33). The most common anatomic regions affected were face/head/neck, extremities, and abdomen. Injuries were responsible for 51.5% of reported surgical conditions. Two of three household deaths involved proximate causes that were surgically treatable. For all met and unmet need, 80% (20 of 25 individuals) were treated or need treatment at a District Hospital or lower level facility.

Prevalence of existing surgical conditions was used in this pilot to compute a nation-wide study sample size of 4,750. The pilot study cost USD 25/respondent and averaged 36 minutes per household. Major revisions in deployment of the nation-wide survey included: hiring enumerators who lived in the EAs, random household sampling, shift in data collection equipment, and improving breath and depth of data acquired by the SOSAS instrument.

Conclusion The prevalence of existing surgical conditions in Wakiso District was within range of previous pilot studies deploying the same SOSAS instrument, albeit not from Uganda. A large proportion of individuals have surgical problems that can be treated at District Hospital or lower level facilities. The pilot study was feasible and necessary to inform deployment of the nation-wide survey.

Background: Uganda is experiencing a high rate of Traumatic Brain Injuries (TBI), approximately 170 per 100,000 when compared to the global rate of 106 per 100,000. This may be due to an increasing rate of road traffic incidents (RTIs) and falls. LMICs like Uganda are disproportionately burdened with a higher number of RTI and other risk factors for TBI. One of the foremost reasons for poor outcomes for moderate and severe TBI patients are the delays in seeking, reaching, and receiving care. The aim of this study is to understand the perceptions of pre-hospital and in-hospital delays in seeking, reaching, and receiving care for patients diagnosed with TBI at Mulago National Referral Hospital (MNRH), and obtain perceptions of interventions that could reduce delay for these patients.

Methods: The study is a qualitative research project and will be carried out at Mulago National Referral Hospital, Kampala district, Uganda. The study participants were healthcare professionals in the Neurological ward of this hospital. This study will utilize semi-structured in-depth qualitative interviews, outlined through “The Three Delay Framework”, to understand perceptions of the reasons behind the three delays: seeking, reaching, and receiving care. Additionally, collecting perspectives on what can be done about the delays.

Results: During the study period, fourteen healthcare professionals in the Neurological ward of MNRH were interviewed. Of the fourteen, three were senior neurosurgeons, six were neurosurgical residents, and five were nurses. Four themes were derived from the data, Transportation, Knowledge and Stigma, Surgical Intervention Preparedness, and Financial Burdens. Nineteen sub-themes or sub-codes were found during analysis and were deductively pre-coded for either delay or solution. Transportation Means, Physical Distance, Road Conditions, Injury Knowledge, Hospital Knowledge, Hospital Stigma, Communicable Disease Information, Instruments, Resources, Staff, Space, Equipment, Investigations, Cost of Obtaining care, Cost of Transport, Cost of Cheaper Care, Cost of Investigations, Cost of Surgical Equipment, and Cost of Medication are all found within the four main themes.

Conclusions: Understanding perceptions of delay and methods to reduce them from the prospective of the healthcare professional established confirmation of current issues affecting care at MNRH. The data also demonstrated the issue of understanding the delays but not methods to solve them. Interviews with patients and their families are the next step in understanding these prevalent issues and creating an appropriate intervention to reduce them.

Introduction: Epilepsy is one of the most prevalent neurological diseases in the world. In Sub-Saharan Africa, people with epilepsy frequently seek treatment from traditional or pastoral healers, who are more accessible than biomedical care providers. This is problematic because it often contributes to a time delay preventing patients from obtaining adequate biomedical care. In Uganda, biomedical providers who treat epilepsy are also available, including neurologists and psychiatrists. This study sought to elucidate the barriers to biomedical care for people with epilepsy as well as identify potential solutions to overcome these barriers.

Methods: The study used qualitative research methods. Semi-structured interviews and focus group discussions were conducted with four major groups: patients with epilepsy or family members of patients with epilepsy, neurologists and psychiatrists, pastoral healers, and traditional healers. All interviews and focus group discussions that were in English were audio recorded and transcribed verbatim into English. Those that were not in English were translated live and audio recorded. A translator later translated the audio recording to ensure proper transcription into English. Two independent coders coded the dataset and conducted an inter-rater reliability assessment to ensure reliable coding of the data. Thematic analysis was then performed to elucidate themes from the data and to compare nuances in the themes between each of the study design groups.

Results: Participants in this study discussed several different causes of epilepsy ranging from spiritual to biological causes, but often incorporating elements of both. Common spiritual causes of epilepsy included witchcraft and ancestral spirits. Common biological causes included genetics, fever, malaria, and brain injury. For patients and families, beliefs about the cause of epilepsy often played a role in whom they chose to seek treatment from.

Three major barriers to biomedical care were discussed: practical barriers, barriers relating to medical infrastructure, and barriers related to stigma against people with epilepsy. Practical barriers included logistical barriers such as transportation, cost of medical care, and distance to the nearest healthcare facility. Under medical infrastructure, drug stockouts and lack of access to anti-epileptic drugs were the most consistent problems stated amongst patients. Stigma was heavily discussed and brought up by nearly every participant. Additionally, three significant solutions to improving epilepsy care in Uganda were highlighted by participants: collaboration among treatment providers, community sensitization efforts to address stigma, and building medical infrastructure. Within building infrastructure, all participant types except traditional healers proposed the development of an epilepsy clinic designed to specifically treat epilepsy.

Conclusions: Based on these findings, there are four critical interventions that should be considered for improving epilepsy care in Uganda: collaboration between biomedical providers and traditional healers, community outreach programs for sensitization, the establishment of epilepsy clinics, and infrastructure building to address medication stockouts.