Traumatic spinal cord injuries in rural Tanzania : occurrences, clinical outcomes and life situations of persons living in the Kilimanjaro region

Background: Traumatic spinal cord injury (TSCI) is one of the most troubling health condition as it leaves the inflicted individual with irreversible sensorimotor impairment. Rural areas of Tanzania and other low income countries are characterized by inadequate emergency, medical and rehabilitation services and are mostly inaccessible by wheelchair. The studies in this thesis aimed to create an understanding of the epidemiology, clinical outcomes of SCI, as well as living with the condition, in a typical rural area of a low-income country. Methods: Four studies were conducted with two being hospital-based and two carried out in the community. A retrospective study assessed the magnitude, etiology and clinical outcomes for past five years (2010-2014) by using patients’ data from archives of the Kilimanjaro Christian Medical Centre (KCMC). In the same setting, another study assessed the same variables prospectively for one year (2017) with greater focus being placed on classifying severity of injury and health complications. In the community, a qualitative study was used to conceptualize coping resources for persons with SCI in one study, while in another, the WHOQoL-BREF questionnaire was used to assess the quality of life of these persons quantitatively. Results: The retrospective study obtained 213 full patient records in which the leading cause of injury was falls 104(48.8%) followed by road traffic accidents 73(34.3%). The annual incidence for the Kilimanjaro region (population 1,640,087) was estimated at more than 26 persons per million for this period. The most documented complications were pressure ulcers at 19.7%, respiratory complications at 15.0% and multiple complications at 13.1%. The in-hospital mortality rate was 24.4%. The prospective study involved 87 persons who sustained SCI in 2017, of whom 66.7% were due to falls (especially from a position of height), 28.7% to road traffic accidents and 4.6% from other causes. The annual incidence rate based on Kilimanjaro region (population 1,910, 555) was estimated at more than 38 new cases per million. The majority of the injuries occurred at the cervical 56.3% and lumbar 31% levels. Most of the injuries 59.8% were incomplete while 40.2% were complete. The questionnaire study reports that the majority of the participants rated their quality of lives as neither poor nor good 39(48.8%) and poor life 20(25%). The mean score for domains of QoL showed the highest score in social relations and psychological well-being, while the lowest scores were rated for physical health and environment. There was no significant mean difference in the score of domains based on sociodemographic characteristics, except for physical environment in which quadriplegia scored lower than paraplegia (p = 0.038). The qualitative interview study identified acceptance as the core category for identification and utilization of both internal and external coping resources for persons with TSCI in the community. Internal coping resources related to personal factors and external coping resources related to family and community were found to be important. Conclusion: Most of the traumatic SCI in Kilimanjaro rural area are due to falls, followed by road traffic accidents. SCI-related complications are common and hospital mortality is still high. Persons with SCI faces various challenges pertaining to health and accessibility that affect them physically, socially and environmentally. Establishment of emergency and critical care services, trauma registries, community-based rehabilitation and population-based surveys would address major issues pertaining to TSCI in these areas