Browsing by Author "Justine Davies"
Now showing 1 - 20 of 22
Results Per Page
Sort Options
Item All-cause mortality of hospitalised patients with suspected COVID-19 in Sierra Leone: a prospective cohort study(2023-02-05) Olivia Farrant; Mamadu Baldeh; Joseph Baio Kamara; Emma Bailey; Stephen Sevalie; Gibrilla Deen; James Baligeh Walter Russell; Daniel Youkee; Andy JM Leather; Justine Davies; Sulaiman LakohObjectives To study the mortality of patients with COVID-19 in Sierra Leone, to explore the factors associated with mortality during the COVID-19 pandemic and to highlight the complexities of treating patients with a novel epidemic disease in a fragile health system. Study design A prospective single-centre cohort study. Data were extracted from paper medical records and transferred onto an electronic database. Specific indicators were compared between survivors and non-survivors, using descriptive statistics in Stata V.17. Study setting The infectious diseases unit (IDU) at Connaught Hospital in Freetown, Sierra Leone Participants Participants were all patients admitted to the IDU between March and July 2020. Aims of study The primary outcome of the study was to examine the all-cause mortality of hospitalised patients with suspected COVID-19 in Sierra Leone and the secondary outcome measures were to examine factors associated with mortality in patients positive for COVID-19. Results 261 participants were included in the study. Overall, 41.3% of those admitted to the IDU died, compared with prepandemic in-hospital mortality of 23.8%. Factors contributing to the higher mortality were COVID-19 infection (aOR 5.61, 95% CI 1.19 to 26.30, p=0.02) and hypertension (aOR 9.30, 95% CI 1.18 to 73.27, p=0.03) Conclusions This study explores the multiple factors underpinning a doubling in facility mortality rate during the COVID-19 pandemic in Sierra Leone . It provides an insight into the realities of providing front-line healthcare during a pandemic in a fragile health system.Item Are cardiovascular health measures heritable across three generations of families in Soweto, South Africa? A cross-sectional analysis using the random family method(2022-09-23) Lisa J Ware; Innocent Maposa; Andrea Kolkenbeck-Ruh; Shane A Norris; Larske Soepnel; Simone Crouch; Juliana Kagura; Sanushka Naidoo; Wayne Smith; Justine DaviesObjectives: Cardiovascular disease is increasing in many low and middle-income countries, including those in Africa. To inform strategies for the prevention of cardiovascular disease in South Africa, we sought to determine the broad heritability of phenotypic markers of cardiovascular risk across three generations. Design: A cross-sectional study conducted in a longitudinal family cohort. Setting: Research unit within a tertiary hospital in a historically disadvantaged, large urban township of South Africa. Participants: 195 individuals from 65 biological families with all three generations including third-generation children aged 4-10 years were recruited from the longest running intergenerational cohort study in Africa, the Birth to Twenty Plus cohort. All adults (grandparents and parents) were female while children were male or female. Primary and secondary outcome measures: The primary outcome was heritability of blood pressure (BP; brachial and central pressures). Secondary outcomes were heritability of arterial stiffness (pulse wave velocity), carotid intima media thickness (cIMT) and left ventricular mass indexed to body surface area (LVMI). Results: While no significant intergenerational relationships of BP or arterial stiffness were found, there were significant relationships in LVMI across all three generations (p<0.04), and in cIMT between grandparents and parents (p=0.0166). Heritability, the proportion of phenotypic trait variation attributable to genetics, was estimated from three common statistical methods and ranged from 23% to 44% for cIMT and from 21% to 39% for LVMI. Conclusions: Structural indicators of vascular health, which are strong markers of future clinical cardiovascular outcomes, transmit between generations within African families. Identification of these markers in parents may be useful to trigger assessments of preventable risk factors for cardiovascular disease in offspring.Item Bodymass index and diabetes risk in 57 lowincome and middleincome countries a crosssectional study of nationally representative individuallevel data in 685616 adultsFelix Teufel; Jacqueline A Seiglie; Pascal Geldsetzer; Michaela Theilmann; E et al; Justine DaviesItem Burden of mortality linked to community-nominated priorities in rural South Africa(2021-11-26) Pyry Mattila; Justine Davies; Denny Mabetha; Stephen Tollman; Lucia D’AmbruosoBackground: Community knowledge is a critical input for relevant health programmes and strategies. How community perceptions of risk reflect the burden of mortality is poorly understood. Objective: To determine the burden of mortality reflecting community-nominated health risk factors in rural South Africa, where a complex health transition is underway. Methods: Three discussion groups (total 48 participants) representing a cross-section of the community nominated health priorities through a Participatory Action Research process. A secondary analysis of Verbal Autopsy (VA) data was performed for deaths in the same community from 1993 to 2015 (n = 14,430). Using population attributable fractions (PAFs) extracted from Global Burden of Disease data for South Africa, deaths were categorised as ‘attributable at least in part’ to community-nominated risk factors if the PAF of the risk factor to the cause of death was >0. We also calculated ‘reducible mortality fractions’ (RMFs), defined as the proportions of each and all community-nominated risk factor(s) relative to all possible risk factors for deaths in the population . Results: Three risk factors were nominated as the most important health concerns locally: alcohol abuse, drug abuse, and lack of safe water. Of all causes of deaths 1993–2015, over 77% (n = 11,143) were attributable at least in part to at least one community-nominated risk factor. Causes of attributable deaths, at least in part, to alcohol abuse were most common (52.6%, n = 7,591), followed by drug abuse (29.3%, n = 4,223), and lack of safe water (11.4%, n = 1,652). In terms of the RMF, alcohol use contributed the largest percentage of all possible risk factors leading to death (13.6%), then lack of safe water (7.0%), and drug abuse (1.3%) . Conclusion: A substantial proportion of deaths are linked to community-nominated risk factors. Community knowledge is a critical input to understand local health risks.Item Cardiovascular disease risk profile and management practices in 45 lowincome and middleincome countries A crosssectional study of nationally representative individuallevel survey dataD Peiris; A Ghosh; J Manne-Goehler; L Jaacks; E et al; Barnighausen Till; Justine DaviesItem Diagnostic testing for hypertension, diabetes, and hypercholesterolaemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveys(2023-09) Sophie Ochmann*; Isabelle von Polenz*; Maja-Emilia Marcus; Michaela Theilmann; David Flood; Kokou Agoudavi; Krishna Kumar Aryal; Silver Bahendeka; Brice Bicaba; Pascal Bovet; Luisa Campos Caldeira Brant; Deborah Carvalho Malta; Albertino Damasceno; Farshad Farzadfar; Gladwell Gathecha; Ali Ghanbari; Mongal Gurung; David Guwatudde; Corine Houehanou; Dismand Houinato; Nahla Hwalla; Jutta Adelin Jorgensen; Khem B Karki; Nuno Lunet; Joao Martins; Mary Mayige; Sahar Saeedi Moghaddam; Omar Mwalim; Kibachio Joseph Mwangi; Bolormaa Norov; Sarah Quesnel-Crooks; Negar Rezaei; Abla M Sibai; Lela Sturua; Lindiwe Tsabedze; Roy Wong-McClure; Justine Davies; Pascal Geldsetzer; Till Bärnighausen; Rifat Atun†; Jennifer Manne-Goehler†; Sebastian Vollmer†Background—Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemographic inequalities. We aimed to address this knowledge gap. Methods—In this cross-sectional analysis, we pooled individual-level data for non-pregnant adults aged 18 years or older from nationally representative surveys done between Jan 1, 2010, and Dec 31, 2019 in LMICs that included a question about whether respondents had ever had their blood pressure, glucose, or cholesterol measured. We analysed diagnostic testing performance by quantifying the overall proportion of people who had ever been tested for these cardiovascular risk factors and the proportion of individuals who met the diagnostic testing criteria in the WHO package of essential noncommunicable disease interventions for primary care (PEN) guidelines (ie, a BMI >30 kg/m2 or a BMI >25 kg/m2 among people aged 40 years or older). We disaggregated and compared diagnostic testing performance by sex, wealth quintile, and education using two-sided t tests and multivariable logistic regression models. Findings—Our sample included data for 994 185 people from 57 surveys. 19·1% (95% CI 18·5– 19·8) of the 943 259 people in the hypertension sample met the WHO PEN criteria for diagnostic testing, of whom 78·6% (77·8–79·2) were tested. 23·8% (23·4–24·3) of the 225 707 people in the diabetes sample met the WHO PEN criteria for diagnostic testing, of whom 44·9% (43·7– 46·2) were tested. Finally, 27·4% (26·3–28·6) of the 250 573 people in the hypercholesterolaemia sample met the WHO PEN criteria for diagnostic testing, of whom 39·7% (37·1–2·4) were tested. Women were more likely than men to be tested for hypertension and diabetes, and people in higher wealth quintiles compared with those in the lowest wealth quintile were more likely to be tested for all three risk factors, as were people with at least secondary education compared with those with less than primary education. Interpretation—Our study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested.Item Estimating the burden of cardiovascular risk in community dwellers over 40 years old in South Africa Kenya Burkina Faso and GhanaRyan Wagner; Nigel Crowther; Lisa Micklesfield; R Boua; E Nonterah; F Mashinya; S Mohamed; E et al; Stephen Tollman; Michele Ramsay; Justine DaviesItem Evaluating the collection comparability and findings of six global surgery indicatorsH Holmer; A Bekele; L Hagander; E Harrison; Martin Smith; E et al; Justine DaviesItem Evaluation of sex differences in dietary behaviours and their relationship with cardiovascular risk factors a crosssectional study of nationally representative surveys in seven lowand middleincome countriesB McKenzie; J Santos; P Geldsetzer; Justine Davies; J Manne-Goehler; Barnighausen Till; E et alItem Global economic burden of unmet surgical need for appendicitis(2022-09-09) Anna Reuter; Lisa Rogge; Mark Monahan; Mwayi Kachapila; Dion G Morton; Justine Davies; Sebastian Vollmer; NIHR Global Surgery CollaborationBackground: There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and $73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and $75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially.Item Lower limb amputations among individuals living with diabetes mellitus in low- and middle-income countries: A systematic review protocol(2022-04-14) Eyitayo Omolara Owolabi; Davies Adeloye; Anthony Idowu AjayiID; Michael McCaul; Justine Davies; Kathryn M. ChuThe burden of diabetes mellitus (DM) and its associated complications continue to burgeon, particularly in low- and middle-income countries (LMICs). Lower limb amputation (LLA) is one of the most life-altering complications of DM, associated with significant morbidity, mortality and socio-economic impacts. High-income countries have reported a decreasing incidence of DM-associated LLA, but the situation in many LMICs is unknown. We aim to conduct a systematic review to determine the incidence and prevalence of DMassociated LLA in LMICs to better inform appropriate interventions and health system response. Methods and analysis A systematic search of the literature will be conducted on five databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus and African Journal Online (AJOL). Only observational, quantitative studies reporting the incidence and/or prevalence of DM-related LLA will be considered. A validated study designspecific critical appraisal tool will be used to assess the risk of bias in individual studies. We will determine the incidence of LLA by examining the number of new cases of LLA among individuals with confirmed DM diagnosis during the specified period, while the prevalence will be based on the total number of all new and existing LLAs in a population. LLA will be considered as the resection of the lower limb from just above the knee to any point down to the toe. If heterogeneity is low to moderate, a random-effects meta-analysis will be conducted on extracted crude prevalence/incidence rates, with the median and interquartile range also reported. The systematic review will be performed in accordance with the JBI guideline for prevalence and incidence review. Study reporting will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline.Item Obesity, hypertension, and tobacco use associated with left ventricular remodeling and hypertrophy in South African women: Birth to Twenty Plus Cohort(2022) Andrea Kolkenbeck‑Ruh; Larske M. Soepnel; Simone H. Crouch; Sanushka Naidoo; Wayne Smith; Shane A. Norris; Justine Davies; Lisa J. WareBackground: Left ventricular hypertrophy (LVH) is a marker of increased risk in developing future life-threatening cardiovascular disease (CVD), however, it is unclear how CVD risk factors, such as obesity, blood pressure (BP), and tobacco use, are associated with left ventricular (LV) remodeling and LVH in urban African populations. Therefore, we aimed to identify the prevalence of LVH as well as the health factors associated with LV remodeling and LVH, within black South African adult women and their pre-pubescent children. Methods: Black female adults (n=123; age: 29–68 years) and their children (n=64; age: 4–10; 55% female) were recruited from the Birth to Twenty Plus Cohort in Soweto, South Africa. Tobacco and alcohol use, physical activity, presence of diabetes mellitus, heart disease, and medication were self-reported. Height, weight, and blood pressure were measured in triplicate to determine the prevalence of obesity and hypertension respectively. Echocardiogra‑ phy was used to assess LV mass at end-diastole, based on linear measurements, and indexed to body surface area to determine LVH. Results: Hypertension and obesity prevalences were 35.8% and 59.3% for adults and 45.3% and 6.3% for children. Self-reported tobacco use in adults was 22.8%. LVH prevalence was 35.8% in adults (75% eccentric: 25% concentric), and 6.3% in children. Concentric remodeling was observed in 15.4% of adults, however, concentric remodeling was only found in one child. In adults, obesity [OR: 2.54 (1.07–6.02; p=0.02)] and hypertension [3.39 (1.08–10.62; p=0.04)] signifcantly increased the odds of LVH, specifcally eccentric LVH, while concentric LVH was associated with selfreported tobacco use [OR: 4.58 (1.18–17.73; p=0.03)]. Although no logistic regression was run within children, of the four children LVH, three had elevated blood pressure and the child with normal blood pressure was overweight. Conclusions: The association between obesity, hypertension, tobacco use, and LVH in adults, and the 6% prevalence of LVH in children, calls for stronger public health eforts to control risk factors and monitor children who are at risk.Item Prevalence and risk factors of lower extremity disease in high risk groups in Malawi a stratified crosssectional studyS Kasenda; A Crampin; Justine Davies; J K Malava; S Manganizithe; E et alItem Prevalence and risk factors of lower extremity disease in high risk groups in Malawi: a stratified cross-sectional study(2022-10-10) Stephen Kasenda; Amelia Crampin; Justine Davies; Jullita Kenala Malava; Stella Manganizithe; Annie Kumambala; Becky SandfordObjective: Low/middle-income countries face a disproportionate burden of cardiovascular diseases. However, among cardiovascular diseases, burden of and associations with lower extremity disease (LED) (peripheral arterial disease and/or neuropathy) is neglected. We investigated the prevalence and factors associated with LED among individuals known to have cardiovascular disease risk factors (CVDRFs) in Malawi, a low-income country with a significant prevalence of CVDRFs. Design: This was a stratified cross-sectional study. Setting: This study was conducted in urban Lilongwe Area 25, and the rural Karonga Health and Demographic Surveillance Site. Participants: Participants were at least 18 years old and had been identified to have two or more known CVDRFs. Main outcome measures: LED-determined by the presence of one of the following: neuropathy (as assessed by a 10 g monofilament), arterial disease (absent peripheral pulses, claudication as assessed by the Edinburgh claudication questionnaire or Ankle Brachial Pulse Index (ABPI) <0.9), previous amputation or ulceration of the lower limbs. Results: There were 806 individuals enrolled into the study. Mean age was 52.5 years; 53.5% of participants were men (n=431) and 56.7% (n=457) were from the rural site. Nearly a quarter (24.1%; 95% CI: 21.2 to 27.2) of the participants had at least one symptom or sign of LED. 12.8% had neuropathy, 6.7% had absent pulses, 10.0% had claudication, 1.9% had ABPI <0.9, 0.9% had an amputation and 1.1% had lower limb ulcers. LED had statistically significant association with increasing age, urban residence and use of indoor fires. Conclusions: This study demonstrated that a quarter of individuals with two or more CVDRFs have evidence of LED and 2.4% have an amputation or signs of limb threatening ulceration or amputation. Further epidemiological and health systems research is warranted to prevent LED and limb loss.Item Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop(2022-04-15) Tamlyn Mac Quene; Luné Smith; Maria Lisa Odland; Susan Levine; Lucia D’Ambruoso; Justine Davies; Kathryn ChuBackground: Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. Objective: To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. Methods: A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. Results: Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider’s knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. Conclusions: This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.Item Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop(2022-12) Tamlyn Mac Quene; Luné Smith; Maria Lisa Odland; Susan Levine; Lucia D’Ambruoso; Justine Davies; Kathryn ChuBackground: Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. Objective: To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. Methods: A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. Results: Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. Conclusions: This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.Item Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop(2022-04-14) Tamlyn Mac Quene; Luné Smith; Maria Lisa Odland; Susan Levine; Lucia D’Ambruoso; Justine Davies; Kathryn ChuBackground: Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. Objective: To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. Methods: A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. Results: Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider’s knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. Conclusions: This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.Item Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making(2021-10-25) Lucia D’Ambruoso; Jessica Price; Eilidh Cowan; Gerhard Goosenf; Edward Fottrell; Kobus Herbst; Maria van der Merwe; Jerry Sigudla; Justine Davies; Kathleen KahnBackground: Recognising that the causes of over half the world’s deaths pass unrecorded, the World Health Organization (WHO) leads development of Verbal Autopsy (VA): a method to understand causes of death in otherwise unregistered populations. Recently, VA has been developed for use outside research environments, supporting countries and communities to recognise and act on their own health priorities. We developed the Circumstances of Mortality Categories (COMCATs) system within VA to provide complementary circumstantial categorisations of deaths. Objectives: Refine the COMCAT system to (a) support large-scale population assessment and (b) inform public health decision-making. Methods: We analysed VA data for 7,980 deaths from two South African Health and SocioDemographic Surveillance Systems (HDSS) from 2012 to 2019: the Agincourt HDSS in Mpumalanga and the Africa Health Research Institute HDSS in KwaZulu-Natal. We assessed the COMCAT system’s reliability (consistency over time and similar conditions), validity (the extent to which COMCATs capture a sufficient range of key circumstances and events at and around time of death) and relevance (for public health decision-making). Results: Plausible results were reliably produced, with ‘emergencies’, ‘recognition, ‘accessing care’ and ‘perceived quality’ characterising the majority of avoidable deaths. We identified gaps and developed an additional COMCAT ‘referral’, which accounted for a significant proportion of deaths in sub-group analysis. To support decision-making, data that establish an impetus for action, that can be operationalised into interventions and that capture deaths outside facilities are important. Conclusions: COMCAT is a pragmatic, scalable approach enhancing functionality of VA providing basic information, not available from other sources, on care seeking and utilisation at and around time of death. Continued development with stakeholders in health systems, civil registration, community and research environments will further strengthen the tool to capture social and health systems drivers of avoidable deaths and promote use in practice settings.Item Staff recognition and its importance for surgical service delivery A qualitative study in Freetown Sierra LeoneJustine Davies; C Willott; N Boyd; AJM LeatherItem Telemedicine in Surgical Care in Low and MiddleIncome Countries A Scoping ReviewE O Owolabi; T M Quene; J Louw; Justine Davies; K.M Chu