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Introduction A significant number of climbers on Mount Kilimanjaro are affected by altitude-related disorders. The aim of this study was to determine the main causes of morbidity and mortality in a representative cohort of climbers based on local hospital records. Methods We conducted a 2-y retrospective chart review of all patients presenting to the main referral hospital in the region after a climb on Mount Kilimanjaro, including all relevant records and referrals for postmortem studies. Results We identified 62 climbers who presented to the hospital: 47 inpatients and 15 outpatients. Fifty-six presented with high altitude illness, which included acute mountain sickness (n=8; 14%), high altitude pulmonary edema (HAPE) (n=30; 54%), high altitude cerebral edema (HACE) (n=7; 12%), and combined HAPE/HACE (n=11; 20%). The mean altitude of symptom onset ranged from 4600±750 m for HAPE to 5000±430 m for HAPE/HACE. The vast majority of inpatients (n=41; 87%) were improved on discharge. Twenty-one deceased climbers, most having died while climbing (n=17; 81%), underwent postmortem evaluation. Causes of death were HAPE (n=16; 76%), HAPE/HACE (n=3; 14%), trauma (1), and cardiopulmonary (1). Conclusions HAPE was the main cause of death during climbing as well as for hospital admissions. The vast majority of climbers who presented to hospital made a full recovery.

Road traffic injuries (RTIs) cause significant morbidity and mortality in low- and middle-income countries. Investigation of high risk areas for RTIs is needed to guide improvements. This study provides built environmental analysis of road traffic crash hotspots within Moshi, Tanzania. Spatial analysis of police data identified 36 hotspots. Qualitative comparative analysis revealed 40% of crash sites were on local roads without night lighting and increased motorcycle density. Paved narrow roads represented 26% of hotspots and 13% were unpaved roads with uneven roadsides. Roadside unevenness was more predominate in low risk [n = 19, (90.5%)] than high risk sites [n = 7 (46.7%)]. Both low [n = 6 (28.6%)] and high risk [n = 1 (6.7%)] sites had minimal signage. All sites had informal pedestrian pathways. Little variability between risk sites suggests hazardous conditions are widespread. Findings suggest improvement in municipal infrastructure, signage and enforcement is needed to reduce RTI burden.

Aims To develop Swahili versions of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE questionnaires and evaluate their psychometric properties in a traumatic brain injury (TBI) population in Tanzania. Methods Swahili versions of the AUDIT and CAGE were developed through translation and back-translation by a panel of native speakers of both English and Swahili. The translated instruments were administered to a sample of Tanzanian adults from a TBI registry. The validity and reliability were analyzed using standard statistical methods. Results The translated versions of both the AUDIT and CAGE questionnaires were found to have excellent language clarity and domain coherence. Reliability was acceptable (>0.85) for all tested versions. Confirmatory factor analysis of one, two and three factor solution for the AUDIT and one factor solution for the CAGE showed adequate results. AUDIT and CAGE scores were strongly correlated to each other (R > 0.80), and AUDIT scores were significantly lower in non-drinkers compared to drinkers. Conclusions This article presents the first Swahili and Tanzanian adaptations of the AUDIT and CAGE instruments as well as the first validation of these questionnaires with TBI patients. Both instruments were found to have acceptable psychometric properties, resulting in two new useful tools for medical and social research in this setting.

Background Annually, over 10 million people worldwide suffer a traumatic brain injury (TBI). Using Kilimanjaro Christian Medical Center’s (KCMC) TBI Clinical Registry, we aim to evaluate the impact of time to treatment for TBI patients presenting to the KCMC emergency department. Method A secondary analysis of all KCMC TBI Registry patients between May 2013-August 2016 included demographics, vital signs, Glasgow Coma Score (severe 3–8, moderate 9–12 or mild 13–15), time to critical interventions and Glasgow Outcome Score (GOS) (poor 1–3, good 4–5). We use descriptive statistics and linear regression analysis to assess for associations with improved GOS. Results Of the 3209 total patients, most (82.1%) were males who suffered road traffic injuries (67.4%) with an average age of 32.1 (SD16.6). 386 (12%) patients had a severe TBI, GCS 3–8. 2798 (87%) of patients saw a physician within one hour of arrival and 1267 (39.5%) had lab testing within an hour of seeing a physician. Overall, 10.15% of patients had poor outcome. Linear regression analysis showed that moderate and severe GCS were the largest predictors of a poor outcome with OR of 8.4 (5.8–12.2) and 38.8 (28.6–53.1) respectively. When stratifying by GCS, for moderate and severe GCS patients, delay or absence of receiving a CT scan (OR 2.3, 1.6–8.5) and oxygen (OR 2.7, 1.15–6.7) were associated with poor outcomes. Conclusions Most TBI patients at KCMC are young men, suffering road traffic injuries and who see a physician within one hour of arrival at the hospital. Initial GCS is the best predictor of a poor outcome. Delay to CT scan and oxygen were predictors of poor outcome for patients with moderate and severe GCS.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Background Globally, alcohol is responsible for 3.3 million deaths annually and contributes to 5.9% of the overall global burden of disease. In Sub-Saharan Africa, alcohol is the leading avoidable risk factor accounting for a substantial portion of death and disability. This project aimed to determine the proportion of injuries related to alcohol and the increased risk of injury due to alcohol among injury patients seeking care at the emergency department (ED) of Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Methods A representative cross-sectional sample of adult patients presenting to the KCMC ED with acute injury were enrolled in this study with a nested case-crossover design. Patient demographics, injury characteristics, and severity as well as alcohol use behaviors were collected. Alcohol breathalyzers were administered to the enrolled patients. Data on activities and alcohol use were collected for the time period 6 h prior to injury and two control periods: 24–30 h prior to injury and 1 week prior to injury. Results During 47 weeks of data collection, 24,070 patients were screened, of which 2164 suffered injuries, and 516 met the inclusion and exclusion criteria, consented to participate, and had complete data. Of the study participants, 76% were male, and 30% tested positive for alcohol on arrival to the ED. Alcohol use was associated with being male and being employed. Alcohol use was associated with an increased risk of injury (OR 5.71; 95% CI 3.84–8.50), and specifically road traffic injuries were associated with the highest odds of injury with alcohol use (OR 6.53, 95% CI 3.98–10.71). For all injuries and road traffic injuries specifically, we found an increase in the odds of injury with an incremental increase in the dose of alcohol. Conclusions At KCMC in Moshi, Tanzania, 3 of 10 injury patients tested positive for alcohol on presentation for care. Similarly, alcohol use conveys an increased risk for injury in this setting. Evidence-based prevention strategies for alcohol-related injuries need to be implemented to reduce alcohol misuse and alcohol-related injuries.

Annually, alcohol causes 3.3 million deaths; countless more alcohol-related injury patients are treated in emergency departments (EDs) worldwide. Studies show that alcohol-related injury patients reduce their at-risk alcohol-use behavior with a brief negotiational interview (BNI) in the ED. This project aims to identify potential perceived barriers to implementing a BNI in Tanzania. A knowledge, attitude, and practice questionnaire was piloted and administered to all emergency department health care practitioners, including physicians, advanced medical officers, and nurses. The questionnaire included the Perceived Alcohol Stigma (PAS) Scale. The survey was self-administered in English, the language of health care instruction, with a Swahili translation available if preferred. Data were analyzed with relative and absolute frequencies and Spearman's correlation. Thirty-four (100%) health care practitioners completed the survey. Our results found positive attitudes toward addressing alcohol misuse (88%), but very poor knowledge of recommended alcohol-use limits (24%). Participants were willing to discuss alcohol use (88%) and to screen (71%) for alcohol-use disorders. Most health care practitioners report significant stigma against those with alcohol-use disorders (39% discrimination, 53% devaluation, 71% either). Counseling patients about high-risk alcohol use was directly and positively associated with at-risk alcohol and counseling education and believing it was common to ask patients about tobacco and alcohol use; it was negatively associated with believing it was 'not my role' or that knowing about alcohol use 'won't make a difference'. Stigma was negatively and indirectly associated with counseling patients. In conclusion, in an ED in Tanzania, health care practitioners have positive attitudes toward addressing at-risk alcohol use, and endorsed having training in alcohol misuse in school. Unfortunately, participants did not demonstrate knowledge of recommended alcohol limit guidelines. Similarly, among practitioners, there is a significant discrimination and devaluation stigma against those who misuse alcohol. These factors must be addressed prior to a successful implementation of an alcohol harm reduction intervention.

Road traffic injuries (RTIs) continue to increase with the proliferation of motor vehicles, especially in low-income countries where safe road infrastructure is lacking. Knowing where and why RTIs occur would allow for increased safety and prevention planning. In this study, police records of 300 motor vehicle collisions which occurred between February 2013 and January 2014 in Moshi, Tanzania were reviewed. Analysis of variables including victim age, gender, type of collision, conditions, and use of safety equipment were analyzed. Geographic information system (GIS) analysis was performed to identify areas with the most collisions. Most injuries occurred at four intersections on two main corridor. Car crashes represented 48% of reports while motorcycle collisions were 35% of reports. Victims were predominantly male. The majority (64%) of RTI victims in cars used seatbelts while only 43% of motorcyclists wore helmets; none of those who used the helmet or seatbelt suffered a grievous injury. These data demonstrate that RTIs in Moshi occur in predictable high traffic locations. RTIs injure victims of all backgrounds and safety equipment is not universally utilized. More investment is needed in improved data collection methods, and a greater emphasis on intersection safety is needed to reduce these preventable injuries.

Background Traffic crashes are a major cause of global morbidity and mortality disproportionately affecting low- and middle-income countries (LMICs). Motorcycle taxi (boda boda) drivers are particularly vulnerable because they are exposed to traffic risks with limited safety equipment. This study aims to characterize injury prevalence and safety habits among boda boda drivers, as well as ways to improve road traffic safety in LMICs. Methods A cross-sectional mixed methods study was conducted with 300 boda boda drivers between 24 March and 3 April 2014 in urban Moshi, Tanzania. A convenience sample of participants was drawn from 25 of 58 registered boda boda stands and 2 of 31 unregistered stands. Data were analyzed using R, and content thematic analysis was performed and agreed upon by three investigators. Logistic regression models were used to evaluate the association between boda boda characteristics and injury risk. Results In total, 300 drivers participated, of whom 148 (49.3%) had experienced a crash during their lifetime, and 114 (77.0%) sustained at least one injury. Only 27 of those injured (23.4%) were hospitalized. Of all participants, 220 (73.3%) reported consistent helmet usage, despite 285 participants (95.0%) agreeing that helmet usage reduces injury severity. From the 280 helmets observed, 231 (82.5%) were either damaged or fit improperly. Having a cracked helmet was associated with higher risk of being involved in a traffic crash. Owning a helmet with a proper fit was associated with reduced risk for a traffic crash (OR = 0.06) and road traffic injuries (OR = 0.07). A thematic analysis of boda boda drivers' suggestions to increase road safety identified four intervention areas: 1) roadway infrastructure and traffic regulation, 2) road user attitudes and safe driving behaviors, 3) education and training, and 4) law enforcement. Conclusion Our study demonstrates boda boda drivers' safety behaviors and identifies four intervention areas that can be leveraged to increase overall road traffic safety. Unfortunately, while boda boda drivers are aware of ways to improve safety, adherence to safety habits remains low. Successful multi-sectoral interventions are needed to improve road safety for boda boda drivers in Tanzania.

Traumatic brain injury (TBI) is the most common cause of death and disability globally disproportionately affecting low- and middle-income countries where increasing injury rates are compounded by limited quality care. The objective of this study is to describe quality of care for TBI patients who presented to Kilimanjaro Christian Medical Center, Moshi, Tanzania. We evaluated a prospective quality improvement TBI registry that enrolled consecutive patients with acute TBI. Descriptive statistics and qualitative comparative analysis was performed. Overall, 893 TBI patients were enrolled during the study period, with a mean age of 32.1 years and who were mostly (80%) male. 12.9% suffered severe TBI (GCS9). Most injuries were road traffic (66%) especially motorcyclists (49%) and 26.8% were alcohol related. One intubation occurred, and 22.9% of hypoxic patients received oxygen. Severe TBI mortality was 47%. TBI affects men 15-45 years old in traffic crashes with high mortality for severe TBI (47%) patients. Care addressing secondary injury, hypoxemia, and hypotension is limited.

Background Road traffic injuries (RTI) are a significant cause of morbidity and mortality in low and middle income countries (LMIC). Further investigations of the high risk areas for RTIs in LMIC are needed to guide improvements in road safety planning. This study aims to provide a built environmental analysis of road traffic crash hotspots within Moshi, Tanzania. Methods After ethical and police permission, Moshi police data was collected and descriptive statistics were tabulated. Hotspots were identified through spatial analysis and relevant patterns in environmental characteristics determined using Qualitative Comparative Analysis (QCA). Results 36 Hotspots were identified. QCA revealed 40% of crash sites were found on local roads, without night lighting and had increased motorcycle density. A further 26% of hotspots were located on paved narrow roads and 13% of hotspots were described as unpaved roads with uneven roadside areas. Roadside unevenness was more predominate in low risk sites, (High risk n = 7 (46.7%), Low risk n = 19, 90.5%, p = 0.01). Both low and high risk sites had minimal signage (High risk n = 1 (6.7%), low risk n = 6 (28.6%) and all had informal pedestrian pathways (High risk n = 15 (100%), low risk n = 21 (100%) . Conclusions In Moshi, Tanzania hotspots were associated with roadside dangers, lack of night lighting, informal pedestrian pathways, and increased traffic density but overall there was little variability between the low and high risk sites suggesting hazardous road conditions exist throughout the area. Our findings suggest overall improvement in municipal infrastructure, including structural improvements, signage and enforcement are needed to help reduce road traffic injury burden.

Background Road traffic crashes are a major cause of global morbidity and mortality, disproportionately affecting low- and middle-income countries. Motorcycle taxi (boda-boda) drivers are particularly vulnerable because they have limited protection and safety equipment. This study characterises injury prevalence and safety habits amongst boda-boda drivers, and identifies intervention points to improve road safety. Methods A prospective mixed methods interview and safety assessment was administered to 300 boda-boda drivers in urban Moshi, Tanzania. Participants were chosen randomly from 25 of 58 registered boda-boda stands and 2 of 31 unregistered stands. The survey was administered using a computerised, internet based survey tool (REDCAPS) and tablet computers. Data were analysed using R, and a thematic analysis was performed and agreed upon by three investigators (MP, TN, CS). Results Of the 148 participants (49.3%) who had experienced a crash, 114 (77.0%) sustained at least one injury. Only 27 of those injured (23.4%) were hospitalised. 220 participants (73.3%) reported consistent helmet usage despite the fact that 285 participants (95.0%) agree that helmet usage reduces injury severity. Of the 280 helmets observed, 231 (82.5%) were either damaged or fit improperly. A thematic analysis of boda-boda drivers’ suggestions to increase road safety identified four intervention points: 1) roadway infrastructure and traffic regulation, 2) road user attitudes and safe driving behaviours, 3) education and training, and 4) law enforcement. Conclusions The present study demonstrates the high prevalence of road traffic injuries amongst boda-boda drivers. The study identifies four intervention points that can be leveraged to increase overall road traffic safety. Unfortunately, while boda-boda drivers are aware of ways to improve safety, adherence to safety habits remains low. Successful interventions will bridge the gap between knowledge and practice of safety habits.

Background Traumatic Brain Injury (TBI) is the most common cause of injury death and disability globally. While TBI increases mental health burden, there is no current literature in low and middle-income countries (LMIC) about these patients. This project evaluated the pre-injury mental health of TBI at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Methods Surveys were conducted of TBI patients between May September 2015. Participants were >18 years old and responded at discharge the questionnaires: PHQ-9, Kessler, CES-D, and AUDIT. Data were descriptively represented and questionnaires classified according to the cut-offs: PHQ-9 >4, CES >15, Kessler >20, and AUDIT >7. Frequences, means with standard deviations (sd) were reported and a spearman correlation was used to evaluate associations. Results Of all 77 TBI patients, most are male (84%) with mean age of 35 (sd 13) and married (61%). Patients were mainly farmers, skilled or unskilled workers or work in business. While a small percentage of patients have signs of depression (2.6% to 9.1%) and anxiety (4.2%) prior to their injury, a significant proportion have harmful or hazardous drinking behaviour (42.9%). A moderate correlation was observed between depression and anxiety symptoms (R = 0.44 and R = 0.51). A small and not significant association was found between hazardous or harmful drinking and depression (R = −0.02 and R = −0.09) or anxiety (R = 0.02) amongst this population. Conclusions This is the first report of pre-injury mental health of TBI patients in Tanzania. Although significant proportions of patients did not show large mental health systems hazard or harmful alcohol use was concerningly high. However, association patterns demonstrated that patients with harmful or hazardous drinking are not the same with depression and anxiety score. This is an important preliminary finding to understand the baseline mental health status of our TBI patients in a low income setting.

Traumatic brain injury (TBI) currently has a global incidence rate of 200 per 100 000 people per year. A growing public health issue, the burden of TBI is distributed disproportionately with the highest incidence rates of 170 per 100 000 people per year in Sub Saharan Africa. The young productive population between the ages of 15 and 45, particularly males have been shown to be at a significantly higher risk for TBI. When strategizing resource allocation in limited resource settings it is important to understand the current capacity of the system and where the barriers to access to care lie to improve outcomes and lower the socioeconomic burden of TBI. This is a prospective cohort study to understand the state of pre-hospital care available and barriers to care for patients presenting at a major referral hospital with neurosurgical capacity over 4 months, in Moshi Tanzania. Preliminary results show that of 337 patients enrolled none received pre-hospital care including first aid, 63% of patients use more than one mode of transport to reach the hospital with the private car being the mode on the first leg and ambulance being the mode on the second leg. The mean time to reach the hospital is 55 min after departure from point of injury. The average patient arrives at the hospital just within the golden hour where treatment has been shown to have a significant effect on outcome yet mortality is high. Contributing factors are analysed using multivariable regression for association to worse outcome measured by Glasgow Outcome Score. Consideration is taken to control for variables such as age and presenting Glasgow Coma Score. Following the descriptive analysis of barriers to care ore TBI patients in this setting recommendations are made for policy and clinical practice guidelines to improve outcomes.