Community-based perceptions of emergency care in Zambian communities lacking formalised emergency medicine systems

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.

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.

A needs assessment for formal emergency medicine curriculum and training in Zambia

Emergency medicine (EM) is a nascent field in Zambia. While not yet recognized as a medical specialty, there is national interest for developing more robust emergency care systems in this setting. One key element of strengthening EM in Zambia is identifying current gaps in emergency healthcare provision and opportunities for advancement in the field. This research used a modified version of the Emergency Care Assessment Tool to characterize the landscape of EM in Zambia. We collected data on the extent of EM training and teaching engagement among physicians practicing EM in Zambia. The survey assessed three aspects of core EM "signal functions" among the respondents which included; how often they performed the function, how confident they felt with the function, and how important they deemed the function to be in their practice. Finally, we asked respondents to identify barriers to performing the functions in their departments. The majority of respondents were early in their career, all below the age of 50, and participated in some form of teaching and supervision of learners, with minimal access to teaching resources to enhance their work. There was unanimous agreement with the need for formal postgraduate EM training in Zambia. The EM functions performed least often by EM physicians, and in which they felt the least confident, were high-acuity low-occurrence (HALO) procedures such as surgical airway and pericardiocentesis. The most common barrier to performing an EM function was access to supplies, equipment and medication. The second most commonly cited barrier was healthcare worker training. This research identified several critical needs for EM curricula in Zambia, specifically teaching resources for clinicians who supervise learners, directed learning on HALO procedures, and formal postgraduate training in EM based in Zambia.

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.

Emergency Scenario-Based Training Curriculum Development: Enhancement of Caregivers for the Elderly' Emergency Assistance Competency in a Rural Thai Community

Background

Caregivers for the elderly are a critical component of the health care system, especially in rural communities. They play a crucial role, assisting older people in confronting emergency illnesses.

Objective

The study describes the process of developing an emergency scenario-based training curriculum (ESBTC) for caregivers of the elderly, focusing on geriatric life-threatening surveillance and emergency assistance (GLTSEA) in rural communities.

Methods

The descriptive qualitative research utilized for developing the ESBTC followed Karn's six steps of curriculum development: (1) needs assessment, (2) targeted needs assessment, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback. The research sample comprised community representatives engaged in providing care during emergency illnesses, emergency experts, and health care providers. A group discussion and focus group were conducted along with semi-structured interviews. The data were analyzed by content analysis following Creswell's six steps.

Results

The results revealed problems and needs related to the care and management of emergency illnesses in rural communities. Five main themes emerged, including insufficient knowledge, difficulties in communication, mindfulness and self-confidence, Unable to assess the initial symptoms, and a need for skills development. In the development step, the curriculum focused on skill development and continued follow-up to ensure necessary skills, such as providing basic life support, using automated external defibrillators, through training scenarios. In the evaluation step, the participants indicated that their emergency assistance skills had improved. The six main themes that emerged regarding the training continuity, courses, and competencies needed to support the emergency system for caregivers were benefits and value, competence enhancements, upstreaming confidence, sustainable development, challenges in curriculum development, and effective strategies.

Conclusions

The ESBTC combines community-based and realistic scenarios, involving the participation of community stakeholders. It is crucial to gather community feedback and needs assessments to formulate potential strategies as part of the curriculum.

Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs.

METHODS

This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle-Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies.

CONCLUSIONS

The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.

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.

Health-related reasons patients transfer from a clinic or health post to the Emergency Department in a District Hospital in Botswana

Introduction

Rural health clinics in low-resource settings worldwide are usually staffed with health care workers with limited knowledge and skills in managing acute emergencies. The Emergency Centre (EC) at the district hospital or primary hospital serves as an entry point for patients with diverse medical needs from health posts and community clinics. The study described the socio-demographic characteristics, primary diagnosis, and disposition of patients transferred from the clinics and health posts to the district hospital in the Kweneng district.

Method

This study is a chart audit of the triage sheets and admitting medical records (Botswana Integrated Patient Management System, IPMS) conducted for the period June through to December 2020. Descriptive statistics were used to analyze the quantitative data. Frequencies, percentages, and measures of central tendency were calculated using the software, SPSS version 27.

Results

A total of 1565 charts were reviewed; 56% (n = 877) were females and 43.5% (n = 681) were males. Half of the patients presenting to the EC ranged from ages 21 to 50, with a mean age of 36.49. The most frequently reported reason for referral was “trauma,” (23.5%, n = 368) whereas the second common reason for referral was abortion-related complications (14.2%, n = 222). The highest admissions were from abortion-related complications (20.2%, n = 169). Most patients’ transfers were from clinics and health posts outside Molepolole (59.4%, n = 930). More than half of the patients (64.2%, n = 537) transferred from outside Molepolole were admitted than discharged from the EC.

Discussion

Our study has shown significant transfers to a higher facility for emergency care. The higher number of transfers are trauma-related cases, whereas most patients were admitted for abortion-related complications indicating the need for skill-building in trauma care and management of abortions.

Getting to the Emergency Department in time: Interviews with patients and their caregivers on the challenges to emergency care utilization in rural Uganda

Objectives

Karoli Lwanga Hospital and Global Emergency Care, a 501(c)(3) nongovernmental organization, operate an Emergency Department (ED) in Uganda’s rural Rukungiri District. Despite available emergency care (EC), preventable death and disability persist due to delayed patient presentations. This study seeks to understand the emergency care seeking behavior of community members utilizing the established ED.

Methods

We purposefully sampled and interviewed patients and caregivers presenting to the ED more than 12 hours after onset of chief complaint in January-March 2017 to include various ages, genders, and complaints. Semistructured interviews addressing actions taken before seeking EC and delays to presentation once the need for EC was recognized were conducted until a diverse sample and theoretical saturation were obtained. An interdisciplinary and multicultural research team conducted thematic analysis based on descriptive phenomenology.

Results

The 50 ED patients for whom care was sought (mean age 33) had approximately even distribution of gender, as well as occupation (none, subsistence farmers and small business owner). Interviews were conducted with 13 ED patients and 37 caregivers, on the behalf of patients when unavailable. The median duration of patients’ chief complaint on ED presentation was 5.5 days. On average, participants identified severe symptoms necessitating EC 1 day before presentation. Four themes of treatment delay before and after severity were recognized were identified: 1) Cultural factors and limited knowledge of emergency signs and initial actions to take; 2) Use of local health facilities despite perception of inadequate services; 3) Lack of resources to cover the anticipated cost of obtaining EC; 4) Inadequate transportation options.

Conclusions

Interventions are warranted to address each of the four major reasons for treatment delay. The next stage of formative research will generate intervention strategies and assess the opportunities and challenges to implementation with community and health system stakeholders.

Pre-course online cases for the world health organization's basic emergency care course in Uganda: A mixed methods analysis

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Short courses may address a significant gap in health worker training in basic emergency care in Sub-Saharan Africa.

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Online open educational resources could enhance healthcare worker education in Sub-Saharan Africa as Internet access expands and costs decrease.

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Nurses and doctors show differential knowledge retention in blended short courses that may require targeted educational strategies.

Introduction

The Ministry of Health - Uganda implemented the World Health Organization's Basic Emergency Care course (BEC1) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants’ knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases.

Methods

Multiple Choice Questions (MCQs2) and Likert-scale surveys assessed 137 providers’ knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers’ perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions.

Results

Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p < 0.001). The intervention group scored significantly higher on the pre-test MCQ than controls (p = 0.004) and insignificantly higher at all other times (p > 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage.

Conclusion

Basic emergency care courses for low-resource settings can increase frontline providers’ long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries.

Perspectives on the current state of Nigeria's emergency care system among participants of an emergency medicine symposium: a qualitative appraisal

INTRODUCTION

Emergency care systems provide timely and relevant care to the acutely ill and injured. Published commentaries have characterised deficiencies in the Nigerian emergency care system and offered potential solutions but have not included the perspectives of the Nigerian public. A more inclusive approach that includes feedback from the public may help improve the Nigerian emergency care system through better understanding of the needs, values and expectations of the community.

METHODS

Participants of an emergency medicine symposium participated in focus group discussions that were randomly divided into small groups led by two trained facilitators. These facilitators asked open-ended, semistructured questions to lead discussions in the English language. Participant responses were audio-recorded and transcribed verbatim into transcripts. Two independent investigators employed conventional content analysis to code the transcripts until thematic saturation was achieved.

RESULTS

Three descriptive themes emerged characterising the current state of Nigeria's emergency care system as it relates to prehospital care delivery, hospital care delivery and health system governance: rudimentary, vulnerable and disconnected. At the prehospital level, concepts revolved around emergency recognition and response, ambulance and frontline providers, and cultural norms. At the hospital level, concepts centred around the health workforce, clinical competency, hospital capacity and the burden of financial hardship. At the health system level, concepts concentrated on healthcare access and healthcare financing. Opportunities for emergency care system improvement at each component level were identified and explored.

CONCLUSIONS

The participants in this study identified shortcomings and opportunities to improve prehospital care, hospital care and health system governance. The results of this study may help healthcare professionals, policy makers and community leaders identify gaps in the emergency care system and offer solutions in harmony with the needs, values and expectations of the community. If successful, these community-informed interventions may serve as a model to improve emergency care systems throughout Africa.

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.

Pathways to care: a case study of traffic injury in Vietnam

BACKGROUND

Traffic injuries place a significant burden on mortality, morbidity and health services worldwide. Qualitative factors are important determinants of health but they are often ignored in the study of injury and corresponding development of prehospital Emergency Medical Services (EMS), especially in developing country settings. Here we report our research on sociocultural factors shaping pathways to hospital care for those injured on the roads and streets of Vietnam.

METHODS

Qualitative fieldwork on pathways to emergency care of traffic injury was carried out from March to August 2016 in four hospitals in Vietnam, two in Ho Chi Minh City and two in Hanoi. Forty-eight traffic injured patients and their families were interviewed at length using a semi-structured topic guide regarding their journey to the hospital, help received, personal beliefs and other matters that they thought important. Transcribed interviews were analysed thematically guided by the three-delay model of emergency care.

RESULTS

Seeking care was the first delay and reflected concerns over money and possessions. The family was central for transporting and caring for the patient but their late arrival prolonged time spent at the scene. Reaching care was the second delay and detours to inappropriate primary care services had postponed the eventual trip to the hospital. Ambulance services were misunderstood and believed to be suboptimal, making taxis the preferred form of transport. Receiving care at the hospital was the third delay and both patients and families distrusted service quality. Request to transfer to other hospitals often created more conflict. Overall, sociocultural beliefs of groups of people were very influential.

CONCLUSIONS

Analysis using the three-delay model for road traffic injury in Vietnam has revealed important barriers to emergency care. Hospital care needs to improve to enhance patient experiences and trust. Socioculture affects each of the three delays and needs to inform thinking of future developments of the EMS system, especially for countries with limited resources.

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.

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.

Emergency healthcare needs in the Lavender Hill suburb of Cape Town, South Africa: a cross-sectional, community-based household survey

OBJECTIVE

Emergency care is a key component of healthcare systems, but little is known about its real impact on communities. This study evaluated access, utilisation and barriers to healthcare, and specifically emergency care, in the low socioeconomic Cape Town suburb of Lavender Hill.

DESIGN

A cross-sectional, community-based household survey.

SETTING

Lavender Hill suburb in the Cape Flats of Cape Town, South Africa.

PARTICIPANTS

Two-stage cluster sampling was used to identify approximately 13 households in each of 46 clusters, for a total of 608 households. A senior householder responded on behalf of each household surveyed.

PRIMARY OUTCOME MEASURES

Access to, utilisation of and unmet needs related to healthcare at large and emergency care.

RESULTS

In August 2018, 608 households were surveyed, encompassing 2754 individuals, with a response rate of 96.4%. Almost a quarter of respondents (n=663, 24.1%) used the healthcare system within the last year. Female gender, advancing age, lower levels of education, recipients of disability grants, smaller household sizes and living in formal dwellings were factors associated with increased risk of unmet healthcare and emergency care needs. Only a small proportion of respondents (n=39, 1.4%) reported having unmet emergency healthcare needs, with wait times at facilities (n=9, 23.1%), emergency medical service delays (n=7, 17.9%) and personal safety (n=6, 15.4%) being prominent. There was a high prevalence of chronic medical conditions (hypertension, diabetes and dyslipidaemias) and recent deaths predominantly from trauma and malignancy.

CONCLUSION

The emergency healthcare needs of the community appear to be well catered for, although community expectations may not be high and many barriers exist, particularly in accessing emergency care-be it via ambulance services or at healthcare facilities-and caring for chronic diseases in the ageing population. The Lavender Hill community could benefit from programmes addressing chronic disease management and emergency care delivery within the community.

Putting Culture into Prehospital Emergency Care: A Systematic Narrative Review of Literature from Lower Middle-Income Countries

Background:

Prehospital emergency care is cost-effective for improving morbidity and mortality of emergency conditions. However, such care has been discounted in the public health system of many lower middle-income countries (LMICs). Where it exists, the Emergency Medical Service (EMS) system is grossly inadequate, unpopular, and misrepresented. Many EMS reviews in developing countries have identified systemic problems with infrastructure and human resources, but they neglected impacts of sociocultural factors. This study examines the sociocultural dimensions of LMICs’ prehospital emergency systems in order to improve the quality and impact of emergency care in those countries.

Methods:

Qualitative studies on EMS systems in LMICs were systematically reviewed and analyzed using Kleinman’s health system theory of folk, popular, and professional health sectors. Also, the three-delay model of emergency care – seeking, reaching, and receiving – provided a guiding framework.

Results:

The search yielded over 3,000 papers and the inclusion criteria eventually selected 14, with duplicates and irrelevant papers as the most frequent exclusion. Both user and provider experiences with emergency conditions and the processes of prehospital care were described. Sociocultural factors such as trust and beliefs underlay the way emergency care was experienced. Attitudes of family and community shaped service-seeking behaviors. Traditional medicine was often the first point of care. Private vehicles were the main transportation for accessing care due to distrust and misunderstanding of ambulance services.

Conclusion:

The findings led to the discussion on how culture is woven into the patients’ pathway to care, and the recommendation for any future development to place a far greater emphasis on this aspect. Instead of relying purely on the biomedical sector, the health system should acknowledge and show respect for popular knowledge and folk belief. Such strategies will improve trust, facilitate information exchange, and enable stronger healer-patient relationships.

Cross-sectional evaluation of emergency care capacity at public hospitals in Zambia

OBJECTIVES

The last decade has seen rapid expansion of emergency care systems across Africa, although they remain underdeveloped. In Zambia, the Ministry of Health has taken interest in improving the situation and data are needed to appropriately guide system strengthening efforts. The Emergency Care Assessment Tool (ECAT) provides a context-specific means of measuring capacity of healthcare facilities in low- and middle-income countries. We evaluated Zambian public hospitals using the ECAT to inform resource-effective improvements to the nation's healthcare system.

METHODS

The ECAT was administered to the lead clinician in the emergency unit at 23 randomly sampled public hospitals across seven of Zambia's 10 provinces in March 2016. Data were collected regarding hospitals' perceived abilities to perform a number of predefined signal functions - life-saving procedures that encompass the need for both skills and resources. Signal functions (36 for intermediate facilities, 51 for advanced) related to six sentinel conditions that represent a large burden of morbidity and mortality from emergencies. We report the proportion of procedures that each level of hospital was capable of, along with barriers to delivery of care.

RESULTS

Across all hospitals, most of the level-appropriate emergency care procedures could be performed. Intermediate level (district) hospitals were able to perform 75% (95% CI 73.2 to 76.8) of signal functions for the six conditions. Among advanced level hospitals, provincial hospitals were able to perform 68.6% (67.4% to 69.7%) and central hospitals 96.1% (95% CI 93.5 to 98.7) Main failures in delivery of care were attributed to a lack of healthcare worker training and availability of consumable resources, such as medicines or supplies.

CONCLUSION

Zambian public hospitals have reasonable capacity to care for acutely ill and injured patients; however, there is a need for increased training and improved supply chains.

Adapting the emergency first aid responder course for Zambia through curriculum mapping and blueprinting

OBJECTIVES

Community members are often the first to witness and respond to medical and traumatic emergencies, making them an essential first link to emergency care systems. The Emergency First Aid Responder (EFAR) programme is short course originally developed to help South Africans manage emergencies at the community level, pending arrival of formal care providers. EFAR was implemented in two rural regions of Zambia in 2015, but no changes were originally made to tailor the course to the new setting. We undertook this study to identify potential refinements in the original EFAR curriculum, and to adapt it to the local context in Zambia.

DESIGN

The EFAR curriculum was mapped against available chief complaint data. An expert group used information from the map, in tandem with personal knowledge, to rank each course topic for potential impact on patient outcomes and frequency of use in practice. Individual blueprints were compiled to generate a refined EFAR curriculum, the time breakdown of which reflects the relative weight of each topic.

SETTING

This study was conducted based on data collected in Kasama, a rural region of Zambia's Northern Province.

PARTICIPANTS

An expert group of five physicians practising emergency medicine was selected; all reviewers have expertise in the Zambian context, EFAR programme and/or curriculum development.

RESULTS

The range of emergencies that Zambian EFARs encounter indicates that the course must be broad in scope. The refined curriculum covers 54 topics (seven new) and 25 practical skills (five new). Practical and didactic time devoted to general patient care and scene management increased significantly, while time devoted to most other clinical, presentation-based categories (eg, trauma care) decreased.

CONCLUSIONS

Discrepancies between original and refined curricula highlight a mismatch between the external curriculum and local context. Even with limited data and resources, curriculum mapping and blueprinting are possible means of resolving these contextual issues.

Access to out-of-hospital emergency care in Africa: Consensus conference recommendations

Out-of-hospital emergency care (OHEC) should be accessible to all who require it. However, available data suggests that there are a number of barriers to such access in Africa, mainly centred around challenges in public knowledge, perception and appropriate utilisation of OHEC. Having reached consensus in 2013 on a two-tier system of African OHEC, the African Federation for Emergency Medicine (AFEM) OHEC Group sought to gain further consensus on the narrower subject of access to OHEC in Africa. The objective of this paper is to report the outputs and statements arising from the AFEM OHEC access consensus meeting held in Cape Town, South Africa in April 2015. The discussion was structured around six dimensions of access to care (i.e. awareness, availability, accessibility, accommodation, affordability and acceptability) and tackled both Tier-1 (community first responder) and Tier-2 (formal prehospital services and Emergency Medical Services) OHEC systems. In Tier-1 systems, the role of community involvement and support was emphasised, along with the importance of a first responder system acceptable to the community in which it is embedded in order to optimise access. In Tier-2 systems, the consensus group highlighted the primacy of a single toll-free emergency number, matching of Emergency Medical Services resource demand and availability through appropriate planning and the cost-free nature of Tier-2 emergency care, amongst other factors that impact accessibility. Much work is still needed in prioritising the steps and clarifying the tools and metrics that would enable the ideal of optimal access to OHEC in Africa.