Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study

Abstract

BACKGROUND AND OBJECTIVES: Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs. METHODS: A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction). RESULTS: Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up. CONCLUSION: This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.

Commentary: Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low and Middle Income-Countries: A Meta-Epidemiological Study

“…1 This study delves into a meta-epidemiological study employing meta-analysis and meta-regression techniques using Preferred Reporting in Systematic Review and Meta-Analysis guidelines. 2 It aims to unravel the pooled in-hospital and follow-up mortality, as well as the prevalence of neurological deficits after SCIs in LMICs, thus revealing critical knowledge gaps and areas of future actionable course.…”

“…The study also identifies influential factors, including the time elapsed between injury and medical attention, location of injury, the type of injury management, and socioeconomic indicators (such as income inequality, and education). 2 The prolonged duration of seeking medical care is influenced significantly by factors such as access, cost, familiarity, and cultural beliefs which are further hypothesized to contribute to heightened in-hospital severe neurological deficits. [2][3][4] These findings extend far beyond scientific curiosity, beckoning for strategic interventions aimed at enhancing health care access, health care awareness, fortifying infrastructure, and nurturing robust social support systems in LMICs.…”

“…2 The prolonged duration of seeking medical care is influenced significantly by factors such as access, cost, familiarity, and cultural beliefs which are further hypothesized to contribute to heightened in-hospital severe neurological deficits. [2][3][4] These findings extend far beyond scientific curiosity, beckoning for strategic interventions aimed at enhancing health care access, health care awareness, fortifying infrastructure, and nurturing robust social support systems in LMICs. Furthermore, they underscore the inextricable link between social determinants of health and SCI outcomes, offering critical insights that can guide future endeavors to mitigate disparities and advance the well-being of those grappling with SCI in less advantaged regions of the globe.…”

“…These criteria primarily focused on the origin of the studies, their type, and relevance to SCI outcomes in LMICs, ultimately ensuring the research's credibility. 2 However, the authors note that only English studies were included. This exclusionary approach may inadvertently overlook some data.…”