External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study

Equitable access to quality trauma systems in Ghana: a qualitative study

OBJECTIVES

To explore the barriers to accessing quality trauma care after injury in Ghana.

DESIGN

A qualitative study using semi-structured interviews and focus group discussions in one rural and one urban setting. Interviews and focus group discussions were audio recorded, transcribed and thematically analysed using the four-delay framework.

PARTICIPANTS

53 patient participants (n=39 men, n=14 women, mean age=41, SD=15.6, n=38 rural participants, n=15 urban participants) who had an injury not more than 6 months preceding the start of the study.

SETTINGS

15 individual interviews (n=15) and 2 focus group discussions (n=23) were conducted in Yendi (rural setting in Ghana) and 10 individual interviews (n=10) and 1 focus group discussion (n=5) in the Tamale metropolis (urban setting in Ghana).

RESULTS

Our findings showed that when an injury occurred, participants faced multiple barriers across all delays which prevented them from accessing quality injury care. Barriers were a mix of individual, community-level and health-system factors that were interrelated in many ways. Financial difficulties were one of the prominent barriers mentioned by the participants in both settings.

CONCLUSION

This study shows that multiple factors cause an injured patient to delay in seeking care, reaching care, receiving care and remaining in care. Therefore, there is a pressing need for comprehensive, community-driven strategies to strengthen health literacy at the community level. There is also a need for facility-based strategies that would improve the availability of medical and human resources to augment access to quality trauma care. Additionally, if policymakers focus on removing financial barriers to trauma care and strengthening referral systems, especially in the remote and rural areas, it would greatly improve access to quality trauma care in Ghana.

Health system governance for injury care in low- and middle-income countries: a survey of policymakers and policy implementors

INTRODUCTION

Good health system governance is essential for reducing high mortality and morbidity after injury in low- and middle-income countries (LMICs). Unfortunately, the current state of governance for injury care is not known. This study evaluated governance for injury care in Ghana, Pakistan, Rwanda and South Africa, four LMICs with diverse contexts, to allow understanding of similarities or difference in the status of governance systems in different LMICs.

METHOD

This cross-sectional study captured the perceptions of 220 respondents (31 policymakers and 189 policy implementers) on injury care governance using the framework for governance in health system developed by Siddiqi. Input was captured in 10 domains: strategic vision; participation and consensus; rule of law; transparency; responsiveness; equity and inclusion; effectiveness and efficiency; accountability; intelligence and information; and ethics.

RESULT

The median injury care governance score across all domains and countries was 29% (IQR 17-43). The highest median score was achieved in the rule of law (50, 33-67), and the lowest scores were seen in the transparency (0, 0-33), accountability (0, 0-33), and participation and consensus (0, 0-33) domains. Median scores were higher for policymakers (33, 27-48) than for policy implementers (27, 17-42), but the difference was not statistically significant.

CONCLUSION

The four studied countries have developed some of the foundations of good injury care governance, although many governance domains require more attention. The gap in awareness between policymakers and policy implementers might reflect a delayed or partial implementation of policies or lack of communication between sectors. Ensuring equitable access to injury care across LMICs requires investment in all domains of good injury care governance.

Examining the Obstacles to Timely Otolaryngology Care in Ethiopia and Zimbabwe: A Comparative Analysis

This study compares delays in otolaryngologic care between patients in Mekelle, Ethiopia and Harare, Zimbabwe using the Three Delays model. Patient surveys conducted among 46 patients in Zimbabwe during October 2022 and 105 patients in Ethiopia during June 2023 revealed a significantly higher prevalence of delays in seeking and reaching care in Ethiopia. This was in the aftermath of the Tigray War, which damaged the region's health care infrastructure and diminished the trust of patients. In Zimbabwe, there was poor awareness among patients and nonotolaryngologist providers of otolaryngology disease and care capacity leading to delays in seeking and reaching care. Patients in both countries faced delays in receiving appropriate care due to resource limitations, with Ethiopia's constraints worsened by the recent war and Zimbabwe's by consistent health care underfunding. The longest delays were observed in head and neck oncology care. These findings provide a foundation for understanding otolaryngologic care delays in these low- and middle-income countries.

Developing and integrating a destination decision support algorithm into an innovative electronic communication platform to improve injury care service coordination in Rwanda: The Rwanda912 study protocol

Introduction

Delays in getting injured patients to hospital in a timely manner can increase avoidable death and disability. Like many low- or middle-income countries (LMICs), Rwanda experiences delays related to lack of efficient prehospital communication and formal guidelines to triage patients for hospital care. This paper describes the protocol to develop, roll out, and evaluate the effectiveness of a Destination Decision Support Algorithm (DDSA) integrated in an electronic communication platform, '912Rwanda'. The DDSA will facilitate the linkage of patients to health facilities able to treat their condition(s). Work will be conducted in three phases: i. development, ii. training and roll-out, and iii. evaluation.

Methods and analysis

Work will be conducted in the pre-hospital emergency service "SAMU - Service d'Aide Medicale Urgente" and health facilities in Kigali City and Musanze District, which serve predominately urban and rural populations, respectively. We will develop interfaces to capture facility and patient-relevant data, which feed into a guideline-based electronic DDSA to match patients to hospitals. We will assess existing trauma care processes using qualitative and quantitative methodologies. This will be followed by a series of consensus workshops to develop at-scene triage guidelines and agree variables to capture in the interfaces. The DDSA will be developed based on outputs from these workshops and tested against historical ambulance data and expert opinion until acceptable thresholds of performance are passed. User interfaces will be developed and tested using human computer interface design principles.

Discussion

The combined collaborative approach of bringing together experts and software developers, and with deep engagement of Rwandan stakeholders, including leadership of Rwanda Ministry of health through its technical arm, the Rwanda Biomedical Center, should lead to an ambulance communication system which is utilized, sustained, and effective.

Resuming work roles after injury in a low-income context: Multiple factors influencing the return to work outcomes

BACKGROUND

Return to work (RTW) is an important outcome indicator for the effectiveness of rehabilitation services, and the functional status and overall recovery among individuals who have experienced injury. Despite the rising incidence of traumatic injury among economically productive citizens in Ethiopia, there is a paucity of evidence about the RTW status of injury survivors. This study examined factors associated with RTW success and determinants of time to RTW after injury in Ethiopia.

METHODS

An institution-based cross-sectional study was conducted to collect data retrospectively one year after patients arrived at the study setting due to traumatic injuries. Medical records of all patients who visited the emergency room of a large public hospital in Addis Ababa were reviewed. Data were collected from survivors of traumatic injury, interviewed by telephone one year post-injury. Multivariable logistic regression and survival analysis were carried out to explore factors.

RESULTS

Of the 251 participants, 75% were young adults (age

CONCLUSION

The study uncovers factors crucial to RTW planning and interventions, and provides insights to minimize barriers, foster a smooth transition to employment, and optimize survivors' lives after injury.

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Key Words Collapse

MESH Headings

• Humans
• Male
• Female
• Adult
• Return to Work/statistics & numerical data
• Ethiopia/epidemiology
• Wounds and Injuries/epidemiology
• Wounds and Injuries/rehabilitation
• Cross-Sectional Studies
• Young Adult
• Middle Aged
• Poverty
• Adolescent
• Retrospective Studies

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Grants

• University of Gondar

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Affiliation(s)

Ansha Nega Ahmed School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
Marcia Finlayson School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
Adamu Addissie School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
Ayalew Zewdie Addis Ababa Burn, Emergency and Trauma Hospital, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
Rosemary Lysaght School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada

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Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff survey

INTRODUCTION

The burden of injuries globally and in Malawi is substantial. Optimising both access to, and quality of, care in health systems requires attention. We aimed to establish how health facility staff in Karonga, Malawi, perceive barriers to seeking (delay 1), reaching (delay 2) and receiving (delay 3) injury care.

METHOD

We conducted a cross-sectional survey of health facility staff who treat patients with injuries in all health facilities serving the Karonga Demographic Surveillance Site population. The primary outcome was participant perceptions of the importance of delays 1 to 3 following injury. Secondary outcomes were the barriers within each of these delays considered most important and which were considered the most important across all delays stages.

RESULTS

228 staff completed the survey: 36.8% (84/228) were female and 61.4% (140/228) reported being involved in caring for an injured person at least weekly. Delay 3 was most frequently considered the most important delay 35.1% (80/228), with 19.3% (44/228) and 16.6% (38/228) reporting delays 1 and 2 as the most important respectively; 28.9% (66/228) of respondents either did not know or answer. For delay 1 the barrier, "the perceived financial costs associated with seeking care are too great", was considered most important. For delay 2, the barrier "lack of timely affordable emergency transport (formal or informal)" was considered most important. For delay 3, the barrier, "lack of reliably available necessary physical resources (infrastructure, equipment and consumable material)" was considered most important. When considering the most important overall barrier across all delays, the delay 3 barrier, "lack of reliably available necessary physical resources" received the most nominations (41.7% [95/228]).

CONCLUSIONS

Given the awareness of health facility staff of the issues facing their patients, these findings should assist in informing health system planning.

Commonalities and differences in injured patient experiences of accessing and receiving quality injury care: a qualitative study in three sub-Saharan African countries

OBJECTIVES

To understand commonalities and differences in injured patient experiences of accessing and receiving quality injury care across three lower-income and middle-income countries.

DESIGN

A qualitative interview study. The interviews were audiorecorded, transcribed and thematically analysed.

SETTING

Urban and rural settings in Ghana, South Africa and Rwanda.

PARTICIPANTS

59 patients with musculoskeletal injuries.

RESULTS

We found five common barriers and six common facilitators to injured patient experiences of accessing and receiving high-quality injury care. The barriers encompassed issues such as service and treatment availability, transportation challenges, apathetic care, individual financial scarcity and inadequate health insurance coverage, alongside low health literacy and information provision. Facilitators included effective information giving and informed consent practices, access to health insurance, improved health literacy, empathetic and responsive care, comprehensive multidisciplinary management and discharge planning, as well as both informal and formal transportation options including ambulance services. These barriers and facilitators were prevalent and shared across at least two countries but demonstrated intercountry and intracountry (between urbanity and rurality) variation in thematic frequency.

CONCLUSION

There are universal factors influencing patient experiences of accessing and receiving care, independent of the context or healthcare system. It is important to recognise and understand these barriers and facilitators to inform policy decisions and develop transferable interventions aimed at enhancing the quality of injury care in sub-Saharan African nations.

Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise

OBJECTIVE

A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement.

DESIGN

Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations.

SETTING

The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients.

PARTICIPANTS

24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites.

RESULTS

Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making.

DISCUSSION

We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.

Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data

OBJECTIVES

To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care.

DESIGN

Retrospective analysis of existing VA data routinely collected by a demographic surveillance site.

SETTING

Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi.

PARTICIPANTS

Fatally injured members of the HDSS.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system.

RESULTS

Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49).

CONCLUSIONS

VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.

Equitable access to quality injury care; Equi-Injury project protocol for prioritizing interventions in four low- or middle-income countries: a mixed method study

BACKGROUND

Equitable access to quality care after injury is an essential step for improved health outcomes in low- and middle-income countries (LMICs). We introduce the Equi-Injury project, in which we will use integrated frameworks to understand how to improve equitable access to quality care after injury in four LMICs: Ghana, Pakistan, Rwanda and South Africa.

METHODS

This project has 5 work packages (WPs) as well as essential cross-cutting pillars of community engagement, capacity building and cross-country learning. In WP1, we will identify needs, barriers, and facilitators to impactful stakeholder engagement in developing and prioritising policy solutions. In WP2, we will collect data on patient care and outcomes after injuries. In WP3, we will develop an injury pathway model to understand which elements in the pathway of injury response, care and treatment have the biggest impact on health and economic outcomes. In WP4, we will work with stakeholders to gain consensus on solutions to address identified issues; these solutions will be implemented and tested in future research. In WP5, in order to ascertain where learning is transferable across contexts, we will identify which outcomes are shared across countries. The study has received approval from ethical review boards (ERBs) of all partner countries in South Africa, Rwanda, Ghana, Pakistan and the University of Birmingham.

DISCUSSION

This health system evaluation project aims to provide a deeper understanding of injury care and develop evidence-based interventions within and across partner countries in four diverse LMICs. Strong partnership with multiple stakeholders will facilitate utilisation of the results for the co-development of sustainable interventions.

Access to quality care after injury in Northern Malawi: results of a household survey

BACKGROUND

Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury.

METHODS

We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked.

RESULTS

Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142).

CONCLUSION

Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.

Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi

BACKGROUND

Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings.

METHODS AND FINDINGS

To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework.

CONCLUSIONS

By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.

Barriers to equitable access to quality trauma care in Rwanda: a qualitative study

OBJECTIVES

Using the 'Four Delay' framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients', caregivers' and community leaders' perspectives.

DESIGN

A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically.

SETTING

This qualitative study was conducted in Rwanda's rural Burera District, located in the Northern Province, and in Kigali City, the country's urban capital, to capture both the rural and urban population's experiences of being injured.

PARTICIPANTS

Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders.

RESULTS

Multiple barriers were identified cutting across all levels of the 'Four Delays' framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients.

CONCLUSIONS

Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation.

Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi

OBJECTIVES

We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi.

DESIGN

Facilitated group process mapping workshops with summary process mapping synthesis.

SETTING

Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi.

PARTICIPANTS

Fifty-four healthcare workers from various cadres took part.

RESULTS

An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities).

CONCLUSIONS

We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.

Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop

BACKGROUND

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.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review

Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings

A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Summary

Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Access to care following injury in Northern Malawi, a comparison of travel time estimates between Geographic Information System and community household reports

INTRODUCTION

Injuries disproportionately impact low- and middle-income countries like Malawi. The Lancet Commission on Global Surgery's indicators include the population proportion accessing laparotomy and open fracture care, key trauma interventions, within two hours. The "Golden Hour" for receiving facility-based resuscitation also guides injury care system strengthening. Firstly, we estimated the proportion of the local population able to reach primary, secondary and tertiary facility care within two and one hours using Geographic Information System (GIS) analysis. Secondly, we compared community household-reported with GIS-estimated travel time.

METHODS

Using information from a Health and Demographic Surveillance Site (Karonga, Malawi) on road network, facility location, and local staff-estimated travel speeds, we used a GIS-generated friction surface to calculate the shortest travel time from all households to each facility serving the population. We surveyed community households who reported travel time to their preferred, closest, government secondary and tertiary facilities. For recently injured community members, time to reach facility care was recorded. To assess the relationship between community household-reported travel time and GIS-estimated travel time, we used linear regression to generate a proportionality constant. To assess associations and agreement between injured patient-reported and GIS-estimated travel time, we used Kendall rank and Cohen's kappa tests.

RESULTS

Using GIS, we estimated 79.1% of households could reach any secondary facility, 20.5% the government secondary facility, and 0% the government tertiary facility, within two hours. Only 28.2% could reach any secondary facility within one hour, 0% for the government secondary facility. Community household-reported travel time exceeded GIS-estimated travel time. The proportionality constant was 1.25 (95%CI 1.21-1.30) for the closest facility, 1.28 (95%CI 1.23-1.34) for the preferred facility, 1.45 (95%CI 1.33-1.58) for the government secondary facility, and 2.12 (95%CI 1.84-2.41) for tertiary care. Comparing injured patient-reported with GIS-estimated travel time, the correlation coefficient was 0.25 (SE 0.047) and Cohen's kappa was 0.15 (95%CI 0.078-0.23), suggesting poor agreement.

DISCUSSION

Most households couldn't reach government secondary care within recognised thresholds indicating poor temporal access. Since GIS-estimated travel time was shorter than community-reported travel time, the true proportion may be lower still. GIS derived estimates of population emergency care access in similar contexts should be interpreted accordingly.

Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.

Refining circumstances of mortality categories (COMCAT): a verbal autopsy model connecting circumstances of deaths with outcomes for public health decision-making

BACKGROUND

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 Socio-Demographic 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.

Association between traumatic brain injury (TBI) patterns and mortality: a retrospective case-control study

Background: Low and medium income countries (LMICs) such as Kenya experience nearly three times more cases of traumatic brain injury (TBI) compared to high income countries (HICs). This is primarily exacerbated by weak health systems especially at the pre-hospital care level. Generating local empirical evidence on TBI patterns and its influence on patient mortality outcomes is fundamental in informing the design of trauma-specific emergency medical service (EMS) interventions at the pre-hospital care level. This study determines the influence of TBI patterns and mortality. Methods: This was a case-control study with a sample of 316 TBI patients. Data was abstracted from medical records for the period of January 2017 to March 2019 in three tertiary trauma care facilities in Kenya. Logistic regression was used to assess influence of trauma patterns on TBI mortality, controlling for patient characteristics and other potential confounders. Results: The majority of patients were aged below 40 years (73%) and were male (85%). Road traffic injuries (RTIs) comprised 58% of all forms of trauma. Blunt trauma comprised 71% of the injuries. Trauma mechanism was the only trauma pattern significantly associated with TBI mortality. The risk of dying for patients sustaining RTIs was 2.83 times more likely compared to non-RTI patients [odds ratio (OR) 2.83, 95% confidence interval (CI) 1.62-4.93, p=0.001]. The type of transfer to hospital was also significantly associated with mortality outcome, with a public hospital having a two times higher risk of death compared to a private hospital [OR 2.18 95%CI 1.21-3.94, p<0.009]. Conclusion: Trauma mechanism (RTI vs non-RTI) and type of tertiary facility patients are transferred to (public vs private) are key factors influencing TBI mortality burden. Strengthening local EMS trauma response systems targeting RTIs augmented by adequately resourced and equipped public facilities to provide quality lifesaving interventions can reduce the burden of TBIs.

Association between traumatic brain injury (TBI) patterns and mortality: a retrospective case-control study

Background: Low and medium income countries (LMICs) such as Kenya experience nearly three times more cases of traumatic brain injury (TBI) compared to high income countries (HICs). This is primarily exacerbated by weak health systems especially at the pre-hospital care level. Generating local empirical evidence on TBI patterns and its influence on patient mortality outcomes is fundamental in informing the design of trauma-specific emergency medical service (EMS) interventions at the pre-hospital care level. This study determines the influence of TBI patterns and mortality. Methods: This was a case-control study with a sample of 316 TBI patients. Data was abstracted from medical records for the period of January 2017 to March 2019 in three tertiary trauma care facilities in Kenya. Logistic regression was used to assess influence of trauma patterns on TBI mortality, controlling for patient characteristics and other potential confounders. Results: The majority of patients were aged below 40 years (73%) and were male (85%). Road traffic injuries (RTIs) comprised 58% of all forms of trauma. Blunt trauma comprised 71% of the injuries. Trauma mechanism was the only trauma pattern significantly associated with TBI mortality. The risk of dying for patients sustaining RTIs was 2.83 times more likely compared to non-RTI patients [odds ratio (OR) 2.83, 95% confidence interval (CI) 1.62-4.93, p=0.001]. The type of transfer to hospital was also significantly associated with mortality outcome, with a public hospital having a two times higher risk of death compared to a private hospital [OR 2.18 95%CI 1.21-3.94, p<0.009]. Conclusion: Trauma mechanism (RTI vs non-RTI) and type of tertiary facility patients are transferred to (public vs private) are key factors influencing TBI mortality burden. Strengthening local EMS trauma response systems targeting RTIs augmented by adequately resourced and equipped public facilities to provide quality lifesaving interventions can reduce the burden of TBIs.

Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

OBJECTIVES

Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.

DESIGN

A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.

SETTING

This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.

PARTICIPANTS

Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.

RESULTS

Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).

CONCLUSIONS

The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise

Background

Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated.

Methods

A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem.

Results

Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “Training and retention of specialist staff”, “Health education/awareness of injury severity”, “Geographical coverage of referral trauma centres”, and “Lack of protocol for bypass to referral centres”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map.

Conclusion

Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.

Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review

BACKGROUND

Africa accounts forabout 90% of the global trauma burden. Mapping evidence on health systemfactors associated with post-trauma mortality is essential in definingpre-hospital care research priorities and mitigation of the burden. The studyaimed to map and synthesize existing evidence and research gaps on healthsystem factors associated with post-trauma mortality at the pre-hospital carelevel in Africa.

METHODS

A scoping review of published studies and grey literature was conducted. The search strategy utilized electronic databases comprising of Medline, Google Scholar, Pub-Med, Hinari and Cochrane Library. Screening and extraction of eligible studies was done independently and in duplicate.

RESULTS

A total of 782 study titles and or abstracts were screened. Of these, 32 underwent full text review. Out of the 32, 17 met the inclusion criteria for final review. The majority of studies were literature reviews (24%) and retrospective studies (23%). Retrospective and qualitative studies comprised 6% of the included studies, systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%), systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%). Reported post-trauma mortality ranged from 13% in Ghana to 40% in Nigeria. Reported preventable mortality is as high as 70% in South Africa, 60% in Ghana and 40% in Nigeria. Transport mode is the most studied health system factor (reported in 76% of the papers). Only two studies (12%) included access to pre-hospital care interventions aspects, nine studies (53%) included care providers aspects and three studies (18%) included aspects of referral pathways. The types of transport mode and referral pathway are the only factors significantly associated with post-trauma mortality, though the findings were mixed. None of the included studies reported significant associations between pre-hospital care interventions, care providers and post-trauma mortality.

DISCUSSION

Although research on health system factors and its influence on post-trauma mortality at the pre-hospital care level in Africa are limited, anecdotal evidence suggests that access to pre-hospital care interventions, the level of provider skills and referral pathways are important determinants of mortality outcomes. The strength of their influence will require well designed studies that could incorporate mixed method approaches. Moreover, similar reviews incorporating other LMICs are also warranted. Key Words: Health System Factors, Emergency Medical Services [EMS], Pre-hospital Care, Post-Trauma mortality, Africa.

Time-critical conditions: assessment of burden and access to care using verbal autopsy in Agincourt, South Africa

Background

Time-critical conditions (TCC) are estimated to cause substantial mortality in low and middle-income countries. However, quantification of deaths and identification of contributing factors to those deaths are challenging in settings with poor health records.

Aim

To use verbal autopsy (VA) data from the Agincourt health and sociodemographic surveillance system in rural South Africa to quantify the burden of deaths from TCC and to evaluate the barriers in seeking, reaching and receiving quality care for TCC leading to death.

Methodology

Deaths from 1993 to 2015 were analysed to identify causality from TCC. Deaths due to TCC were categorised as communicable, non-communicable, maternal, neonatal or injury-related. Proportion of deaths from TCC by age, sex, condition type and temporal trends was described. Deaths due to TCC from 2012 to 2015 were further examined by circumstances of mortality (CoM) indicators embedded in VA. Healthcare access, at illness onset and during the final day of life, as well as place of death, was extracted from free text summaries. Summaries were also analysed qualitatively using a Three Delays framework to identify barriers to healthcare.

Results

Of 15 305 deaths, 5885 (38.45%) were due to TCC. Non-communicable diseases were the most prevalent cause of death from TCC (2961/5885 cases, 50.31%). CoM indicators highlighted delays in a quarter of deaths due to TCC, most frequently in seeking care. The most common pattern of healthcare access was to die outwith a facility, having sought no healthcare (409/1324 cases, 30.89%). Issues in receipt of quality care were identified by qualitative analysis.

Conclusion

TCCs are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than those in reaching care, and thus further research and solution development should focus on healthcare-seeking behaviour and quality care provision.

Assessing barriers to quality trauma care in low and middle-income countries: A Delphi study

BACKGROUND

Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system.

METHODS

A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement.

RESULTS

There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus.

CONCLUSION

11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.