Injury patterns of patients presenting to a non-governmental hospital in Western Uganda

Community perspectives on barriers to injury care in Northern Malawi: a three delays framed assessment using focus groups and photovoice

INTRODUCTION

The global burden of injury is huge, falling disproportionately on poorer populations. The benefits of qualitative research in injury care are recognised and its application is growing. We used a novel application of focus group discussions with photovoice to rapidly assess barriers at each of three delay stages; seeking (delay-1), reaching (delay-2) or receiving (delay-3) injury care in Northern Malawi.

METHODS

Three community Focus Group Discussions (FGDs) of individuals with (FGD1) and without (FGD2) recent injury experience and community leaders (FGD3) discussed barriers to seeking, reaching or receiving care following injury. Participants from FGD1 subsequently used a digital camera and, following training in photovoice, took photographs illustrating barriers to injury care. Participants reconvened to discuss images which they believed illustrated important barriers. A framework method analysis compared barriers generated to those identified by an earlier Delphi study.

RESULTS

Seven of eight invited adult community members attended each discussion group. Within the FGDs, all prior Delphi derived delay 1 barriers were described. Within delay 2, all but three were discussed by community participants. Those not covered were: 1) "communication" ;2) "prehospital care"; 3) "coordination". Within Delay 3, only "capacity"was not highlighted by participants during the study. Additional health system barriers not identified in the Delphi were inductively derived. Within Delay 1, these were labelled; "religious or other beliefs"; "indecision"; "fear or lacking courage"; and "community/bystander engagement". Within Delay 2, "lack of assistance" was derived. Within Delay 3; "alleged corruption"; "interfacility transfer"; and "police processes" were all identified during analysis. The photovoice group provided 21 photographs evidencing 15 barriers. Delay 1 was the most frequently captured by images (12/21).The individual barriers most frequently described were "transport" and "roads" (6/21 and 5/21, respectively). The photovoice group did not describe any additional barriers not covered in the prior FGDs.

CONCLUSION

We identified several barriers within this health system. Participants illustrated how some barriers impact on multiple phases of delay. The method was quick, low cost and participants grasped the technique and research question effectively. We recommend this approach for future health system assessments.

Piloting a Layperson Prehospital Care System in Rural Uganda

INTRODUCTION

In many low-income countries, basic prehospital Emergency Medical Services (EMS) remain under-developed, resulting in significant delays or the complete inability to access care.

STUDY OBJECTIVE

The purpose of this study was to analyze the effectiveness of a layperson EMS training targeting motorcycle taxi (boda) drivers in a rural region of Uganda.

METHODS

Fifty (50) adult boda drivers from Masindi, Uganda were selected for a one-day training course including lectures and simulation. Course content covered basic prehospital skills and transport. Participants were given a first responder kit at completion of the course. Understanding of material was assessed prior to training, immediately after course completion, and four months from the initial course using the same ten question test. Test means were analyzed using a standard linear regression model. At the four-month follow up, all 50 boda drivers participated in semi-structured small group qualitative interviews regarding their perception of the course and experiences implementing course skills in the community. Boda drivers were asked to complete a brief form on each patient transported during the study period. For patients transported to Masindi Kitara Medical Center (MKMC), hospital trauma registry data were analyzed.

RESULTS

Trainees showed both knowledge acquisition and retention with pre-test scores of 21.8% improving to 48.0% at course completion and 57.7% at the four-month follow up. Overall, participant's scores increased by an average of 35% from the pre-test to the second post-test (P <.001). A total of 69 patient forms were completed on transported patients over the initial four-month period. Ninety-five percent (95%) of these were injured patients, and motorcycle crash was the predominant mechanism of injury (48% of injuries). Eight patients were transported to MKMC, but none of these patients were recorded in the hospital trauma registry. Major barriers identified through semi-structured interviews included harassment by police, poor road conditions, and lack of basic resources for transport. Ninety-four percent (94%) of trainees strongly agreed that the training was useful. Total costs were estimated at $3,489 USD, or $69 per trainee.

CONCLUSION

Motorcycle taxi drivers can be trained to provide basic prehospital care in a short time and at a low cost. While there is much enthusiasm for additional training and skill acquisition from this cohort, the sustainability and scalability of such programs is still in question.

The Kampala Trauma Score: A 20-year track record

ABSTRACT

Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.