Feasibility of Electronic Patient-Reported Outcome Measures following Spinal Injuries in Tanzania

Abstract

Objective

Traumatic spinal injuries are common in resource-limited environments and cause severe consequences such as pain, weakness, numbness, impaired bladder, bowel and sexual function, financial burdens, and psychological issues. In-person follow-up is challenging due to financial constraints, physical disability, and limited transportation. Our study aimed to explore the feasibility of using electronic patient-reported outcome measures (PROMs) following spinal injuries in Tanzania.

Methods

From March to June 2023, we prospectively recruited 50 consecutive inpatients with traumatic spinal injuries at Muhimbili Orthopedic Institute in Tanzania. We recorded mobile phone and internet access and administered the Kiswahili-validated version of the SF-8 quality-of-life (QoL) questionnaire. We compared completion rates between in-person and electronic versions in-hospital and assessed postdischarge completion for electronic questionnaires.

Results

A total of 50 participants were included (mean age: 33 years [standard deviation, SD: 14], 43/50 [86%] male). Most had access to a mobile phone (47/50, 94%), and 27/50 (54%) had access to a smartphone. Only 10 participants (20%) completed the electronic PROM. Reasons for lack of completion were: no internet-enabled device (23/50, 46%), internet connectivity (9/50, 18%), unfamiliarity to the electronic forms (5/50, 10%), and lack of motivation to respond (3/50, 6%). All participants completed the in-person SF-8. Post-injury scores were lower than those reported pre-injury (Physical Component Summary Mean: 37(SD:14) v 95(SD:8), Mental Component Summary Mean: 52(SD:19) vs.98(SD:4)).

Conclusion

Electronic PROMs following spinal injuries have low completion rates in Tanzania. In-person inpatient QoL assessment highlighted the significant impact of spinal injuries, emphasizing the importance of developing methods of QoL assessment.

 

MissingLinkText

Keywords

spinal injuries - quality of life - feasibility - electronic questionnaires - Tanzania - Patient Reported Outcome Measures

Background

Spinal trauma can have significant consequences by causing neurological deficits such as limb weakness or numbness, mobility restrictions,[1] impaired bladder and bowel control, sexual dysfunction, or hemodynamic instability.[2] [3] [4] In addition, complications related to the loss of function, such as pressure ulcers,[5] [6] pneumonia, and recurrent urinary tract infections, can complicate recovery and long-term health.[3] [7] [8] The combination of these factors can significantly decrease the quality of life (QoL) of affected individuals.[9] [10] [11] [12] Spinal trauma commonly occurs in young people,[13] [14] with resultant loss of earnings for them and their family, and can have significant social and psychological consequences.[15] [16] [17] The burden of spinal trauma is high in resource-limited settings where it may occur more frequently due to poor road, home, and workplace safety, or high levels of interpersonal violence.[1] [14] [18] [19] [20] People sustaining spinal trauma may be unable to work, becoming dependent on their family, health care, and welfare support.[9] The consequences are even more severe in resource-limited settings, where health care access,[10] social welfare, and the availability of rehabilitation services are limited.[4] [8] [11] [15]

Few studies have investigated the QoL following spinal trauma in resource-limited settings[12] [21] [22] and those that have are restricted to in-hospital follow-up.[23] This may be due to high mortality rates[24] and the difficulty of following up patients with poor mobility who live far from hospitals or may not have economic or practical means to attend clinics.[20] [25] [26] Telephone calls are labour intensive, and we previously could only contact 26% of spinal injuries patients following discharge using telephone calls; Electronic PROMs are routinely used in clinical practice and research in high-income countries for spinal conditions with good response rates, but applicability in resource-limited settings is unknown. Mobile phone ownership, network coverage, internet access, and digital literacy are all rapidly increasing in Tanzania, and text message, social media, and online advertising and surveys are common.[23] [25] [26] [27] [28] [29] [30] However, it is unclear whether electronic PROMs would be feasible to assess outcomes following spinal injuries. We could not find any previous study on the use of electronic PROMs in Tanzania or similar resource-limited settings following spinal injury.[31] [32]

We aimed to establish the feasibility of using an electronic PROM to measure the QoL in spinal injury patients in Tanzania. We assessed whether patients with spinal injuries have a method of receiving electronic invitations and are able to complete the electronic PROM. We aimed to compare results from in-person and electronic completion and to compare demographics and injury characteristics between those able and unable to complete the electronic questionnaire.

 

MissingLinkText

Methods

Study Design

A prospective cohort study was conducted from March to June 2023 at the Muhimbili Orthopedic Institute (MOI), Dar es Salaam, Tanzania. Potential participants were identified through screening of inpatient admissions. We included patients of any age who had sustained traumatic spinal injuries, including traumatic spinal fractures, spinal cord or nerve root injuries, with or without neurological deficits and managed either operatively or conservatively. Participants who could not provide informed consent, who did not wish to be included, who were not admitted to MOI, or who did not have a spinal injury were excluded from the study. For those unable to give consent, the relative giving consent for their medical care was approached, and the patient was included only if the relative gave informed consent on their behalf. Verbal consent was gained for the in-person questionnaires. If participants reported they could complete the electronic questionnaires, they gave written consent on the electronic form. Relatives were also allowed to help the patients complete the electronic questionnaires, as cervical injuries may have affected upper limb function.

Approximately 150 patients per year are admitted to MOI with spinal injuries. Our aim was to establish feasibility, so we chose to recruit for six months or until 50 patients were enrolled, whichever came first. We expected up to 20% in-hospital mortality, which might affect our ability to recruit depending on the timing of mortality. Fifty patients would provide us with a representative sample over time of those admitted with spinal injuries. With a sample size of 50 patients, at the 5% significance level and 80% power, we were enabled to detect a medium effect size of 0.47 for differences between groups able to complete an electronic PROM and those who could not.

 

MissingLinkText

Data Collection Techniques and Tools

Inpatients were asked to complete an in-person questionnaire that included questions about the use of mobile phones, the internet, email, and WhatsApp; their level of education; their ability to complete an electronic questionnaire form; and their preferred methods for receiving the electronic link. Those who agreed to attempt the electronic PROM also received a subsequent in-hospital visit to assess their experience with completion.

The PROM used in this study was the Kiswahili version of the SF-8, which has been previously validated to measure QoL in a population of individuals with injuries in Tanzania.[33] This tool was chosen for its simplicity and ease of completion. It consists of eight questions, each with five to six response options, covering the following domains: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health.

The SF-8 was administered in-person and in-hospital through discussion with the interviewer in either Swahili or English. Participants were asked to report their preinjury QoL and current in-hospital postinjury QoL. The electronic PROM was sent as a link for completion by either WhatsApp or email as preferred by the participant. Participants were asked to complete the form both in-hospital and after discharge. Three reminders by WhatsApp or email were sent to participants who did not respond. Six weeks after discharge, participants who had not completed the electronic questionnaire were deemed to have not responded. The timing of the questionnaires related to the patients' hospital stay is illustrated in the study flow diagram in [Fig. 1].

Fig. 1 Study flow diagram. This shows the flow of patients through the study and the timing of the questionnaires relating to the injury and in-patient course. The screening was performed to ensure the patient was eligible for the study. Both preinjury and postinjury QoL were asked the following admission with the spinal injury. Questionnaire 1 consisted of background, mobile phone, and internet use. Questionnaire 2 consisted of questions about the experience of attempted completion of the electronic questionnaire. The questionnaires are provided in the [Supplementary Material] (available in the online version).

 

MissingLinkText

Data Analysis

Data were analyzed using SPSS version 23 IBM Corp (2015), Armonk, New York, United States. Participant demographics were summarized using mean and standard deviation (SD) for age and frequency and proportions for categorical variables. We assessed for any association of electronic PROM completion with age, gender, payment method (as a marker of socioeconomic status), level and severity of injury, and presence of associated injuries. Chi-square tests were used to assess differences between groups, and independent t-tests for differences in age distribution. Statistical significance was set at 0.05.

SF-8 responses were analyzed by converting the response in each domain to a scale from 0 to 100, with higher scores signifying higher QoL. The Physical Component Summary (PCS) was calculated as the mean score from general health, physical functioning, role limitations due to physical health problems, and bodily pain. The Mental Component Summary (MCS) was calculated as the mean score from vitality (energy/fatigue), social functioning, mental health, and role limitations due to emotional problems as per the scoring instructions.[33] [34] [35] [36] [37] Visual inspection of histograms and the Kolmogorov–Smirnov test confirmed that the SF-8 scores were normally distributed postinjury, so pre- and postinjury scores were compared using paired sample t-tests. The intrarater reliability of in-hospital responses on the in-person and electronic SF-8 was assessed using the intraclass coefficient for those who completed both in-person and electronic questionnaires.

 

MissingLinkText

 

MissingLinkText

Results

Sociodemographics and Injury Characteristics

There were 50 participants with a mean age of 33 (SD: 14). The majority were male (43/50, 86%). Demographics and injury characteristics are shown in [Table 1]. The American Spinal Injuries Association Impairment category A (24/50, 48%) was the most frequent. Most participants did not have any medical insurance and paid for their medical treatment in cash (46/50,92%). Most (31/50, 62%) had no further education after primary level.

Table 1 Demographics and injury characteristics by completion of electronic patient-reported outcome measures

		Completed electronic PROM
		Yes n = 10	No N = 40	p-Value
Age (mean, SD)	33 (14)	30 (13)	35 (14)	0.384
Gender				0.616
Male	43 (86%)	8 (80%)	35 (88%)
Female	7 (14%)	2 (20%)	5 (12%)
Level of injury				0.260
Cervical	18 (36%)	4 (40%)	14 (35%)
Thoracic	17 (34%)	5 (50%)	12 (30%)
Lumbar	15 (30%)	1 (10%)	14 (35%)
AIS				0.560
A	24 (48%)	5 (50%)	19 (48%)
B	7 (14%)	1 (10%)	6 (15%)
C	6 (12%)	0 (0%)	6 (15%)
D	5 (10%)	1 (10%)	4 (10%)
E	8 (16%)	3 (30%)	5 (12%)
Payment type				0.603
Pays cash	46 (92%)	9 (90%)	37 (92%)
Health insured	4 (8%)	1 (10%)	3 (8%)
Schooling level				0.240
Primary	31 (62%)	4 (40%)	27 (67%)
Secondary	9 (18%)	2 (20%)	7 (18%)
Tertiary (university/college)	10 (20%)	4 (40%)	6 (15%)
Had surgery				0.040
Yes	9 (18%)	4 (40%)	5 (12%)
Awaiting surgery	19 (38%)	5 (50%)	17 (43%)
No surgery planned	22 (44%)	1 (10%)	18 (45%)
Other injuries				0.720
TBI	9 (18%)	2 (20%)	7 (18%)
Limb or pelvis injury	8 (16%)	2 (20%)	6 (15%)
Chest injury	3 (6%)	1 (10%)	2 (5%)
None	30 (60%)	5 (50%)	25 (62%)
Respondent				0.686
Patient	38 (76%)	7 (70%)	31 (78%)
Relative	12 (24%)	3 (30%)	9 (22%)

Abbreviations: AIS, American Spinal Injuries Association Impairment Scale; PROM, Patient Reported Outcome Measures; TBI, traumatic brain injury.

Notes: This table compares the overall demographics and injury characteristics between the 10 participants able to complete an electronic PROM and the 40 participants unable to complete the electronic PROM. Categorical data are compared using chi-square tests, and age is compared across groups using the t-test.

 

MissingLinkText

Feasibility of Electronic QoL Questionnaires

Out of the 50 participants, 47 had access to a phone, with 27 having smartphones and 20 having basic phones. Of the 50 participants, 14/50 (28%) had an email address, and 27/50 (54%) used WhatsApp. A total of 24/50 (48%) chose to receive the electronic link through WhatsApp and 3/50 (6%) through email. Only 10 individual participants in total (20%) completed the electronic PROM, either while they were hospitalized (7/50, 14%) or after they were discharged (6/50, 12%). Only 3/50 (6%) completed both. Reasons reported to the researcher for not being able to receive the link or not being able to complete the electronic PROM were: limited internet access (9/50, 18%), unfamiliarity with electronic questionnaires (5/50, 10%), and lack of motivation to respond due to illness (3/50, 6%). The number of participants with phone and internet access and completing the electronic PROM is displayed in [Fig. 2].

Fig. 2 Feasibility flowchart for electronic quality of life questionnaire (image).

[Table 1] shows that those who were able to complete the electronic PROM had similar demographic and injury characteristics to those who did not respond. Although the number of participants with tertiary education (4/10, 40%) was higher in the group who were able to respond compared with those who were not able to respond (6/40, 15%), this was not statistically significant ([Table 1]). The presence of other injuries, cervical injury, injury severity, or need for a relative to complete the questionnaire were not related to the ability to respond to the electronic PROM. All participants completed the in-person questionnaire.

 

MissingLinkText

Quality of Life Before and After Spine Injury

The in-person SF-8 results for the 50 participants showed a significant decline in both the physical and mental components of QoL compared with the reported preinjury levels ([Fig. 3]). The mean PCS scores decreased significantly from 95 (SD: 8) preinjury to 37 (SD: 14) postinjury, with a mean difference of 57.8 (SD: 15), 95% confidence interval [CI] (53.5, 62.2), p = 0.001. The mean MCS scores dropped from 98 (SD: 4) preinjury to 52 (SD: 19) postinjury, resulting in a mean difference of 46.2 (SD: 18), 95% CI (40.9, 51.5), p = 0.001. The preinjury scores were reported retrospectively after the injury in hospital. We did not compare postdischarge QoL due to the small number of electronic responses after discharge.

Fig. 3 Box plot showing the SF-8 component scores. Physical component scores are on the left (green), and mental component scores are on the right (blue). Scores are shown for (1) preinjury retrospectively in-person reported QoL (n = 50), (2) postinjury in-hospital in-person reported QoL (n = 50), (3) postinjury in-hospital electronically reported QoL (n = 7), and (4) postdischarge electronically reported QoL (n = 6). PCS, Physical Component Summary; QoL, quality of life; MCS, Mental Component Summary.

 

MissingLinkText

Comparison between Electronic and In-Person Responses

For those completing both the in-person and electronic SF-8 reporting their in-hospital QoL (n = 7), there was no significant differences between the mean physical component score in person (36, SD: 16) and the mean electronic score (36, SD: 15, p = 0.962) or the mean mental component score in person (47, SD: 11) and the mean electronic score (38, SD: 25, p = 0.441). The intraclass correlation between the electronic and in-person questionnaires was high, 0.84 (p = 0.021) for the physical component score, but low, −0.32 (p = 0.63) for the mental component score.

 

MissingLinkText

 

MissingLinkText

Discussion

There was a high rate of mobile phone access among those sustaining traumatic spinal injuries in Tanzania (47/50, 94%), but only (27/50, 54%) had a smartphone, and only 10/50 (20%) were able to complete a short eight-question electronic PROM to assess their QoL. Lack of internet access due to inability to access a device, connection, or data (28/50, 56%) was the most common reason given for being unable to complete the electronic PROM.

In 2022, it was estimated that mobile internet coverage is present for 81% of the Tanzanian population, but only 26% were able to access this due to the cost of smartphones and data relative to incomes.[28] [38] Our study participants had higher rates of smartphone use (27/50, 54%) than the national average (26%), which fits with reported higher rates of internet access in young men and in the Dar es Salaam region.[38] This shows the importance of evaluating access in the specific population to be studied, as it may be higher or lower than general estimations due to the characteristics of the population. However, even those who owned a smartphone reported a lack of internet access as a reason for non-completion, highlighting the issues with data access as well as hardware availability. At MOI in the capital city of Dar es Salaam where this study took place, the mobile internet coverage with 4G was excellent, but no patient Wi-Fi was available, and so patients had to pay their mobile phone provider for mobile internet access if they wished to have internet access during their inpatient stay. We did not investigate laptop or home computer ownership as this is known to be much less common than smartphone ownership. Our study suggests that for inpatient or post discharge electronic PROM completion, both a compatible device and access to an internet connection would need to be provided.

Although only 5/50 (10%) of participants reported difficulties with electronic questionnaires as the reason for being unable to complete the electronic PROM, this reason may become more important in the future as internet access becomes more widespread. Digital literacy in Tanzania is low on worldwide scales.[28] [38] We deliberately used a short eight-question questionnaire with a simple header on a white background in this first attempt at using electronic PROMs following spinal injury in Tanzania, as these simple design factors are associated with better completion rates. It has been shown that other factors, such as nonmonetary incentives, including statements that others have responded, use of pictures, or personalizing the questionnaires, can improve response rates for electronic PROMs.[39] To maximize responses in the future all of these factors as well as individual training on use of the questionnaires would need to be tested in this population to see which of these maximize response in this population.

We did not find any injury-related characteristics associated with a lack of ability to respond, such as high cervical injury. This may be because we allowed relatives to help complete the questionnaires due to potential physical practical issues with completion following spinal injury. Electronic questionnaires are commonly used successfully in high-income countries following spine trauma, even for cervical injuries, with technological or carer assistance. Response rates of over 80% have been reported for the AO Spine PrOST and SF-36 administered electronically in high-income countries.[40] The SF-8 has also been used successfully in electronic versions in high income countries.[41] This suggests that it is not the questionnaire or the injury that is the barrier to completion. Instead, infrastructure challenges of smartphone ownership, network coverage, internet access, and digital literacy were more important barriers in Tanzania.[28] [29] [38]

In addition to facilitating follow-up when in-person attendance is challenging, electronic questionnaires have also been shown to facilitate discussion and reporting of sensitive topics such as sexual, bladder, and bowel symptoms and mental health.[32] Although we found no disparity in physical component scores between in-person and electronic methods, there was disparity in interclass correlation for the mental component scores, which was low (0.34). This may reflect underreporting of mental health effects of spinal injuries during in-person interviews. Using in-person reporting only risks the mental burden following spinal trauma being underrepresented in resource-limited settings compared with high-income settings, where the use of electronic questionnaires is widespread.[32] [40] [41] The low QoL reported on the in-person SF-8 measure highlights the importance of QoL studies in this population, along with further studies of interventions to prevent and mitigate the effects of spinal injuries.

Given the current rates of device ownership and access to data, electronic PROMs for inpatient or post discharge follow-up after spinal injuries seem unfeasible in this population. Strategies to comprehensively follow-up patients after discharge from hospital in Tanzania and other resource-limited settings will require a multipronged approach. Transport infrastructure, mobility, and cost remain barriers to in-person follow-up,[20] particularly for those far from the hospital or with mobility issues. In urban Ethiopia, only 47% of spinal injuries patients (188 out of 400) could be reached by telephone.[23] We were only able to contact 130/491 (26%) of those with spinal injuries by telephone at MOI. Incorrect, old, or no documented telephone number was the most common reason for lack of contact.[23] Collection of multiple telephone numbers for the patient and relatives, use of text messages, calls, and specific free of charge follow-up clinics with reminders led to follow-up rates of over 80% at MOI for limb fracture studies.[42] However, transport and mobility barriers may be more significant for spinal injuries patients. Text message surveys have also been used successfully for reproductive health advice in Tanzania, suggesting people are willing to use text messages to discuss sensitive topics.[43] [44] However, any requirement for patients to send text messages will also bring costs, so either funding is required for free-text message response services for text message surveys,[43] or strategies need to concentrate on multiple methods of contact and facilitating in-person travel and cost-free clinic attendance.

Although we met our overall aim of establishing the proportions of spinal injuries patients able to complete electronic QoL measures and barriers to completion, our assessment of differences between the electronic and in-person assessments is limited by the small number of electronic questionnaires completed. Our retrospective assessment of preinjury QoL may also have led to higher preinjury QoL assessments as the preinjury QoL (PCS: 95, MCS: 98) was higher than that reported in the general population in Dar es Salaam in 1999 (PCS: 81, MCS: 83).[37] However, the high preinjury QoL may also reflect the young, male population. The post-injury in-person SF-8 scores were significantly lower than reported pre-injury and in the general population, highlighting the significant impact of spinal injuries on QoL ([Fig. 3]). This emphasizes the need to develop accurate, feasible, reliable and valid methods of QoL assessment to facilitate comprehensive support and interventions to address the consequences of spinal injuries and enhance the overall well-being of individuals affected throughout the world.

 

MissingLinkText

Conclusion

Use of electronic questionnaires for collecting QoL data in spinal injury patients in Tanzania had low response rates and was not representative of the whole spinal injuries population. Internet access was the most significant barrier to completion. Comprehensive telephone, text message, and in-person follow-up strategies with cost-free transportation for clinic attendance are needed to ensure representative capture of long-term QoL outcomes in this population.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None declared.

Acknowledgment

We sincerely thank the dedicated MOI staff for their invaluable cooperation and diligent updates of patient information throughout the study. Our heartfelt gratitude extends to all the spine-injured patients who generously consented to participate, making this research possible. We are immensely thankful to the MOI administration, specifically from the Neurosurgery Department, for their unwavering support.

Data Availability Statement

The datasets generated and/or analyzed during the current study are accessible upon reasonable request from the corresponding author. To maintain compliance with ethical and privacy guidelines, the data cannot be openly shared. The research team will carefully review requests for data access to ensure adherence to relevant regulations and the protection of participant confidentiality.

Ethical Approval Statement

This study was approved for ethical clearance by the Muhimbili University of Health and Allied Sciences (MUHAS) Research and Ethics Committee (ref: DE.274/298/01X/39) and approved to take place by the management at Muhimbili Orthopaedic Institute Department of Neurosurgery. Verbal consent was gained for the in-person questionnaires. If participants reported they could complete the electronic questionnaires, they gave written consent on the electronic form.

• References

• 1 Kumar R, Lim J, Mekary RA. et al. Traumatic spinal injury: global epidemiology and worldwide volume. World Neurosurg 2018; 113: e345-e363
• 2 Ametefe MK, Bankah PE, Yankey KP, Akoto H, Janney D, Dakurah TK. Spinal cord and spine trauma in a large teaching hospital in Ghana. Spinal Cord 2016; 54 (12) 1164-1168
• 3 Dijkers MPJM. Quality of life of individuals with spinal cord injury: a review of conceptualization, measurement, and research findings. J Rehabil Res Dev 2005; 42 (3, Suppl 1): 87-110
• 4 Bickenbach J, Officer A, Shakespeare T, von Groote P. World Health Organization, The International Spinal Cord Society; . International Perspectives on Spinal Cord Injury/edited by Jerome Bickenbach, et al. World Health Organization; 2013. . Accessed January 27, 2023 at: https://apps.who.int/iris/handle/10665/94190
• 5 Zakrasek EC, Creasey G, Crew JD. Pressure ulcers in people with spinal cord injury in developing nations. Spinal Cord 2015; 53 (01) 7-13
• 6 Moshi H, Sundelin G, Sahlen KG, Sörlin A. Traumatic spinal cord injury in the north-east Tanzania - describing incidence, etiology and clinical outcomes retrospectively. Glob Health Action 2017; 10 (01) 1355604
• 7 Hossain MS, Harvey LA, Islam MS. et al. A community-based intervention to prevent serious complications and death 2 years after discharge in people with spinal cord injury in Bangladesh (CIVIC): a randomised trial. Spinal Cord 2021; 59 (06) 649-658
• 8 Eaton J, Mukuzunga C, Grudziak J, Charles A. Characteristics and outcomes of traumatic spinal cord injury in a low-resource setting. Trop Doct 2019; 49 (01) 62-64
• 9 Goraczko A, Zurek G, Lachowicz M, Kujawa K, Blach W, Zurek A. Quality of life after spinal cord injury: a multiple case study examination of elite athletes. Int J Environ Res Public Health 2020; 17 (20) 7437
• 10 Khosravi S, Khayyamfar A, Shemshadi M. et al. Indicators of quality of care in individuals with traumatic spinal cord injury: a scoping review. Global Spine J 2022; 12 (01) 166-181
• 11 Management of Spinal Cord Injury in Low Resource Settings. . Physiopedia. Accessed January 29, 2023 at: https://www.physio-pedia.com/Management_of_Spinal_Cord_Injury_in_Low_Resource_Settings
• 12 Moshi H, Sundelin G, Sahlen KG, Sörlin A. Quality of life of persons with traumatic spinal cord injury in rural Kilimanjaro, Tanzania: a community survey. Disabil Rehabil 2021; 43 (20) 2838-2845
• 13 Chiu WT, Lin HC, Lam C, Chu SF, Chiang YH, Tsai SH. Review paper: epidemiology of traumatic spinal cord injury: comparisons between developed and developing countries. Asia Pac J Public Health 2010; 22 (01) 9-18
• 14 Spinal trauma in Tanzania: current management and outcomes. Accessed January 27, 2023 at: https://pubmed.ncbi.nlm.nih.gov/30952133/
• 15 Pacheco Barzallo D, Oña A, Gemperli A. Unmet health care needs and inequality: a cross-country comparison of the situation of people with spinal cord injury. Health Serv Res 2021; 56 (Suppl. 03) 1429-1440
• 16 Liu T, Xie S, Wang Y. et al. Effects of app-based transitional care on the self-efficacy and quality of life of patients with spinal cord injury in China: randomized controlled trial. JMIR Mhealth Uhealth 2021; 9 (04) e22960
• 17 Adhikari SP, Gurung G, Khadka B, Rana C. Factors influencing depression in individuals with traumatic spinal cord injury and caregivers' perceived burden in a low-income country: a cross-sectional study. Spinal Cord 2020; 58 (10) 1112-1118
• 18 Leidinger A, Zuckerman SL, Feng Y. et al. Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania. J Neurosurg Spine 2023; 38 (04) 503-511
• 19 Shakirah Thebus. . Interpersonal violence seen as leading cause of spinal cord injuries in Western Cape. Accessed January 27, 2023 at: https://www.iol.co.za/capeargus/news/interpersonal-violence-seen-as-leading-cause-of-spinal-cord-injuries-in-western-cape-e6e3fa96-9d32-414c-9a51-f424230513d3
• 20 Joiner AP, Tupetz A, Peter TA. et al. Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: a mixed methods study. PLOS Glob Public Health 2022; 2 (06) e0000277
• 21 Solomon RM, Dhakal R, Halpin SJ. et al. Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature. Spinal Cord 2022; 60 (05) 395-403
• 22 Tyagi N, Amar Goel S, Alexander M. Improving quality of life after spinal cord injury in India with telehealth. Spinal Cord Ser Cases 2019; 5: 70
• 23 Laytin AD, Seyoum N, Azazh A, Zewdie A, Juillard CJ, Dicker RA. Feasibility of telephone-administered interviews to evaluate long-term outcomes of trauma patients in urban Ethiopia. Trauma Surg Acute Care Open 2018; 3 (01) e000256
• 24 Hossain MS, Harvey LA, Islam MS, Rahman MA, Glinsky JV, Herbert RD. A prediction model to identify people with spinal cord injury who are at high risk of dying within 5 years of discharge from hospital in Bangladesh. Spinal Cord 2019; 57 (03) 198-205
• 25 Bloemen-Vrencken JHA, de Witte LP, Post MWM. Follow-up care for persons with spinal cord injury living in the community: a systematic review of interventions and their evaluation. Spinal Cord 2005; 43 (08) 462-475
• 26 Woo C, Guihan M, Frick C, Gill CM, Ho CH. What's happening now! Telehealth management of spinal cord injury/disorders. J Spinal Cord Med 2011; 34 (03) 322-331
• 27 Elbur AI, Ma Y, Elsayed ASA, Abdel-Rahman ME. Post-discharge surveillance of wound infections by telephone calls method in a Sudanese Teaching Hospital. J Infect Public Health 2013; 6 (05) 339-346
• 28 Bridging the digital divide to empower rural Tanzania. The Citizen. June 15, 2023 . Accessed July 2, 2023 at: https://www.thecitizen.co.tz/tanzania/news/national/bridging-the-digital-divide-to-empower-rural-tanzania-4270950
• 29 Mwantimwa K. Use of mobile phones among agro-pastoralist communities in Tanzania. Inf Dev 2019; 35 (02) 230-244
• 30 L'Engle KL, Vahdat HL, Ndakidemi E, Lasway C, Zan T. Evaluating feasibility, reach and potential impact of a text message family planning information service in Tanzania. Contraception 2013; 87 (02) 251-256
• 31 Lequin MB, Verbaan D, Jacobs WCH. et al; Leiden-The Hague Spine Intervention Prognostic Study Group, Wilco C Peul, Bart W Koes, Ralph T W M Thomeer, Wilbert B van den Hout, Ronald Brand. Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomised controlled trial. BMJ Open 2013; 3 (05) e002534
• 32 Woodfield J, Hoeritzauer I, Jamjoom AAB. et al; UCES Collaborators, British Neurosurgical Trainee Research Collaborative. Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: a multi-centre prospective cohort study. Lancet Reg Health Eur 2022; 24: 100545
• 33 Pestillo de Oliveira L, Malheiros Caruzzo N, Sakita F. et al. Cross-cultural adaptation and psychometric properties of the SF-8 Questionnaire in Tanzanian Swahili for injury population. Disabilities 2022; 2 (03) 428-438
• 34 Ware J, Kosinski M, Dewey J. et al. How to score and interpret single-item health status measures: a manual for users of the SF-8 Health Survey; 2001 . Accessed July 20, 2023 at: https://www.semanticscholar.org/paper/How-to-score-and-interpret-single-item-health-a-for-Ware-Kosinski/58853f98cfb44636b81a36ea1585b22985ce1bd3
• 35 Lang L, Zhang L, Zhang P, Li Q, Bian J, Guo Y. Evaluating the reliability and validity of SF-8 with a large representative sample of urban Chinese. Health Qual Life Outcomes 2018; 16 (01) 55
• 36 Ware Jr JE, Gandek B, Kosinski M. et al. The equivalence of SF-36 summary health scores estimated using standard and country-specific algorithms in 10 countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol 1998; 51 (11) 1167-1170
• 37 Wyss K, Wagner AK, Whiting D. et al. Validation of the Kiswahili version of the SF-36 Health Survey in a representative sample of an urban population in Tanzania. Qual Life Res 1999; 8 (1-2): 111-120
• 38 Osakwe S, Humeau E, Bavo C, Mushi M. . Tanzania's Digitalisation Journey: Opportunities for value creation. Mobile for Development; 2023 . Accessed August 17, 2024 at: https://www.gsma.com/solutions-and-impact/connectivity-for-good/mobile-for-development/gsma_resources/tanzanias-digitalisation-journey-opportunities-for-value-creation/
• 39 Edwards PJ, Roberts I, Clarke MJ. et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev 2009; 2009 (03) MR000008
• 40 Sadiqi S, Dvorak MF, Vaccaro AR. et al. Reliability and validity of the English Version of the AOSpine PROST (Patient Reported Outcome Spine Trauma). Spine 2020; 45 (17) E1111-E1118
• 41 Turner-Bowker DM, Bayliss MS, Ware Jr JE, Kosinski M. Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Qual Life Res 2003; 12 (08) 1003-1012
• 42 Patterson JT, Albright PD, Jackson JH. et al. Travel barriers, unemployment, and external fixation predict loss to follow-up after surgical management of lower extremity fractures in Dar es Salaam, Tanzania. OTA Int 2020; 3 (01) e061
• 43 Sustainable Cost Models for mHealth at Scale: Modeling Program Data from m4RH Tanzania. Accessed August 22, 2023 at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4733101/
• 44 Vahdat HL, L'Engle KL, Plourde KF, Magaria L, Olawo A. There are some questions you may not ask in a clinic: providing contraception information to young people in Kenya using SMS. Int J Gynaecol Obstet 2013; 123 (Suppl. 01) e2-e6

Publication History

Article published online:
14 August 2025