Pediatric injury care in low-resource hospital settings. Insight from Mozambique, before, during and after the COVID-19 pandemic

Background: Children are a high-risk group for injuries and the burden is disproportionally high in low- resource settings such as the African continent, which has the highest population of children globally. In low-resource settings in sub-Saharan Africa, the COVID19 pandemic exposed known weaknesses of fragile health systems in providing quality pediatric care.

Aim: Set in a low-resource setting, the studies forming this thesis were concerned with how well prepared main hospitals in Mozambique were to care for injured children prior to the COVID-19 pandemic; how the pandemic impacted the burden and care of children, and what clinicians from various levels of care identified as barriers and facilitators in quality pediatric injury care after the pandemic, as well as in the future

Methods: All studies were conducted in hospitals located in Mozambique, a low-income country in the south eastern Africa. Cross-sectional onsite observations and staff interviews were used to describe the preparedness of central hospitals and barriers to quality care at different levels of care. To address the impact of the COVID-19 pandemic, changes over the time, an interrupted times series was done and comparison of differences in child characteristic, injury mechanisms, severity and needs for surgery and Intensive Care Unit stays between 2019 and 2020, “before and during” the pandemic was performed design aligned to the restriction periods implemented countrywide.

Results: All four central hospitals of the country lacked considerable amounts of equipment and medication during the pandemic, resulting in several life-threatening situations for pediatric injured patients. Staff from different levels of care reported the following main barriers for pediatric injury care prehospital care constraints, shortage in child adaptability of resources, inappropriate infrastructure for pediatric emergency care, and shortages in qualified staff. Support and mentorship between professionals and institutions were described by the health workers as the main facilitator. After the implementation of the first COVID-19 restrictions in 2019, the weekly number of pediatric injuries attendance dropped half a percent, but then returned to the levels observed before the restrictions. The drop occurred in road traffic injuries and falls in the first restriction period, but not in injuries occurring at home and burns that increased significantly in the first restriction period. In the second restriction period in 2020 when the restrictions were not so restricted falls increased. There was also an increase in ICU pediatric injury stays and a decrease in discharges.

Conclusion: There is a lack of pediatric injury quality-care threatening in the country’s hospitals due to barriers related to pre-hospital care, material, and infrastructure. Staff sought better training, adequately equipped working environments and well-organized pediatric emergency units. The COVID-19 restrictions implemented in Mozambique in 2020 to contain the pandemic were linked to a reduction in the weekly number of child injuries, in central hospitals, notably for road traffic injuries and falls. When the restrictions were relaxed the drop was not maintained and was accompanied by a rise in falls, burns and injuries occurring in the home. This potentially reflected the fear and hesitancy of the population to go to the hospital or a reduction in exposure to injury. The scope for improvement is noticeable and the thesis findings may help establish priorities to greater results in child injuries.

List of scientific papers

I. Amado, V., Couto, M. T., Filipe, M., Möller, J., Wallis, L., & Laflamme, L. (2023). Assessment of critical resource gaps in pediatric injury care in Mozambique's four largest Hospitals. PloS one. 18(6), e0286288.
https://doi.org/10.1371/journal.pone.0286288

II. Amado, V., Moller, J., Couto, M. T., Wallis, L., & Laflamme, L. (2023). Effect of the COVID-19 pandemic on emergency department attendances for pediatric injuries in Mozambique's central hospitals: an interrupted time series and a comparison within the restriction periods between 2019 and 2020. Trauma surgery & acute care open. 8(1), e001062.
https://doi.org/10.1136/tsaco-2022-001062

III. Amado, V., Trott, S., Möller, J., Couto, M. T., Wallis, L., & Laflamme, L. (2023). Changing patterns in the burden of paediatric injuries during the COVID-19 pandemic: a study in Mozambique's central hospitals. BMC health services research. 23(1), 1071.
https://doi.org/10.1186/s12913-023-10073-x

IV. Amado V, Zandamela A, Couto MT, Wallis L, Laflamme L. Barriers, and facilitators to paediatric injury care in resource poor hospital settings. Perspectives from clinicians from different levels of care in Maputo, Mozambique. [Manuscript]