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Background: Outcome assessment is essential to understand the impact and recovery of burns of the hand and tailor treatment. There is however, a large variety of measures and outcome assessment is often incomplete. The aim was therefore to initiate a set of outcome assessments for use in a clinical setting. Method: A concept set was drafted, based on the framework of the International Classification of Functioning, which distinguished two phases, three patient states and included both patient reported and clinical outcomes. Subsequently, potential assessments were allocated to the various outcomes. This concept was discussed during the European Burns Association congress in 2013 and revised. The revision was sent to 65 colleagues from 28 institutions, accompanied by a survey. Results: Eleven surveys were returned from 16 persons representing 9 institutions from 6 countries. Based on the feedback, final revisions were made. Points raised were time investment and translations of not all assessments already available. Conclusions: With multidisciplinary and international input, a multidimensional set of outcome assessments for burns of the hand has been established, covering almost all domains of functioning. This first step towards more uniform clinical evaluation, will contribute to knowledge on outcome and effectiveness of treatment of hand burns.

This dissertation provides data collected during the development and implementation of an alternative approach to short-term surgical missions. These missions have been the traditional strategy for surgeons from high-income settings to help to improve surgical care in resource-limited settings. This dissertation presents an alternative approach. During the Amsterdam-based international symposium, ‘Surgery in Low Resource Settings,’ held in November 2014, the urgency for collaborative solutions became more evident. On behalf of 65 international organizations and all participants of the symposium, the “Amsterdam Declaration on Essential Surgical Care” was published in April 2015. Chapter 2 describes that the number of people dying from surgical conditions outnumbers the death toll of HIV, malaria, and tuberculosis combined. Surgery should be a part of the United Nations’ post-2015 sustainable development goals. The aim of Chapter 3 is to present baseline information on surgical burn care in sub-Saharan Africa, and establish methods of process and care improvement. A systematic review provides a critical analysis of the available literature on basic surgical care of burn injuries in sub-Saharan Africa, including timing of excision, grafting, and wound dressing techniques. The results show that essential information—such as depth of burns, TBSA, timing of grafting and wound treatment—are unreported in many of the studies. Future studies should include uniform definitions and parameters such as depth of burns, TBSA, timing of grafting, and wound treatment. The aim of Chapter 4 is to present research insights into ‘access to surgical burn care’ in LMICs. Theoretically, the study is guided by investigating timeliness, surgical capacity, and affordability. In conclusion, the study shows that patients face critical barriers to receiving timely and affordable surgical care in the catchment area of Haydom Lutheran Hospital, Tanzania. To assure timely, safe, and affordable burn care for patients in LMICs, support is also needed beyond hospital management on regional and national levels. Short-term reconstructive plastic surgical missions are a well-established routine method of addressing surgical conditions. Chapter 5 provides a systematic review that assessed the effectiveness of short- term reconstructive surgical missions in LMICs. Original studies of short- term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients, and sustainability. Studies with a low follow-up quality could potentially be under-reporting complication rates and overestimating the positive impact of missions. It was concluded that evidence on the patient outcomes of reconstructive plastic surgical missions is scarce and of limited quality. The recommendations were supported by experienced health workers in the field of surgical missions, as recorded in a survey study on surgical missions (Chapter 6). The results showed that training activities were considered most impactful, and reporting on outcome/s, along with long-term follow-up was strongly recommended. According to 94 percent of the participants, the future focus should be on establishing collaborative practices with local actors, and encouraging strategic, long-term changes, under their leadership. Chapter 7 presents insights into the effects of basic reconstructive plastic surgical training activities on participants. The study demonstrates that surgical skills of the participants can improve, and it strengthens the recommendation that training is a key strategy for the much-needed goal of sustainable solutions to meeting the global burden of surgical disease. The larger goal of training activities for health care providers is to obtain a higher standard of care for the patients in need. In the last study, the focus lies on the outcome of post-burn contracture release surgery during the trainings. Based on the results, it can be concluded that contracture release surgery performed during surgical trainings in LMICs can be safe and effective in the long-term.

Summary The few studies that are available show that the burden of burn injuries remains disproportionally high in resource-limited settings. These settings have a high incidence of burns, and due to limited access to safe burn care the mortality and morbidity remains high in these settings. Of all fire-related cases of mortality worldwide, 95% occur in resource-limited settings. Patients who survive are likely to face serious complications, such as burn scar contractures. During my work as a global health specialist, we, the Tanzanian doctors and I, were indeed confronted with a high incidence of burn injuries. We had limited treatment options available and experienced high mortality and morbidity due to burns. From the literature it became evident that little evidence was available regarding burn care in resource-limited settings. Few studies are available on the outcomes of skin grafting procedures, no studies were available that showed how often burn scar contractures developed, and none of the studies were able to prove whether contracture release surgery was effective in the longer-term. There are valuable and useful treatment guidelines available from the International Society for Burn Injuries, specifically aimed for resource-limited settings. However, the Society also pointed out that the evidence for the guidelines was scarce and recommendations were frequently based on expert opinion. Outline of this thesis To evaluate the current state of burn care and to guide future improvements in burn care of underserved populations in resource-limited settings, insight into current treatment and its outcomes is of vital importance. The studies described in this thesis concentrate on three areas: short-term reconstructive surgical missions (Part I); acute burn care (Part II); and burn scar contracture release surgery (Part III).