Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.

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.

Introduction: Antivenom is currently considered standard treatment across the full spectrum of severity for snake envenomation in the United States. Although safe and effective antivenoms exist, their use in clinical practice is not universal. Objective: This study explored physicians’ perceptions of antivenom use and experience with snake envenomation treatment in order to identify factors that influence treatment decisions and willingness to administer. Methods: We conducted a qualitative study including in-depth interviews via online video conferencing with physicians practicing in emergency departments across the United States. Participants were selected based on purposive sampling methods. Data analysis followed inductive strategies, conducted by two researchers. The codebook and findings were discussed within the research team. Findings: Sixteen in-depth interviews with physicians from nine states across the US were conducted. The participants’ specialties include emergency medicine (EM), pediatric EM, and toxicology. The experience of treating snakebites ranged from only didactic education to having treated over 100 cases. Emergent themes for this manuscript from the interview data included perceptions of antivenom, willingness to administer antivenom and influencing factors to antivenom usage. Overall, cost-related concerns were a major barrier to antivenom administration, especially in cases where the indications and effectiveness did not clearly outweigh the potential financial burden on the patient in non-life- or limb-threatening cases. The potential to decrease recovery time and long-term functional impairments was not commonly reported by participants as an indication for antivenom. In addition, level of exposure and perceived competence, based on prior education and clinical experience, further impacted the decision to treat. Resources such as Poison Center Call lines were well received and commonly used to guide the treatment plan. The need for better clinical guidelines and updated treatment algorithms with clinical and measurable indicators was stated to help the decision-making process, especially among those with low exposure to snake envenomation patients. Conclusions: A major barrier to physician use of antivenom is a concern about cost, cost transparency and cost–benefit for the patients. Those concerns, in addition to the varying degrees of awareness of potential long-term benefits, further influence inconsistent clinical treatment practices.

Harmful alcohol use is a leading risk factor for injury-related death and disability in low- and middle-income countries (LMICs). Brief negotiational interventions (BNIs) in emergency departments (EDs) effectively reduce alcohol intake and re-injury rates. However, most BNIs are developed in high-income countries, with limited evidence of their effectiveness in LMICs. To address this gap, we culturally adapted a BNI for alcohol-related injury patients at Kilimanjaro Christian Medical Centre (KCMC), a tertiary hospital in Tanzania. Our study followed the ADAPT guidance to culturally adapt an existing high-income country BNI for use in the KCMC, a tertiary hospital in Tanzania. The adaptation included: 1) a systematic review of effective alcohol harm reduction interventions in similar settings; 2) consultations with local and international healthcare professionals experienced in counseling and substance abuse treatment; 3) group discussions to refine goals and finalize adaptations. The adapted BNI protocol and assessment scales ensured intervention fidelity. At KCMC, 30% of injury patients screened positive for alcohol use disorder (AUD), with a five-fold increased risk of injury, primarily from road traffic accidents and violence. A systematic review highlighted limited data on patient-level interventions in low-resource settings. Our adapted BNI, ‘Punguza Pombe Kwa Afya Yako (PPKAY)’, based on the FRAMES model, showed high feasibility and acceptability, with 84% of interventions achieving ≥80% adherence and 98% patient satisfaction. PPKAY is the first culturally adapted alcohol BNI for injury patients in an African ED. Our study demonstrates our approach to adapting substance use interventions for use in low resource settings and shows that cultural adaptation of alcohol use interventions is feasible, beneficial and empowering for our team. Our study lays a framework and method for other low resourced settings to integrate cultural adaptation into the implementation of a BNI in low resource EDs.

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20–33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43–41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03–0.90]), 0.11 [95% CI 0.01–0.61], 0.14 [95% 0.02–0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors’ orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.