Utilization of district health services by injured persons in a rural area of Ghana

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.

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.

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.

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.

The Feasibility of a Randomized Controlled Trial for Open Tibial Fractures at a Regional Hospital in Uganda

BACKGROUND

The inclusion of low and middle-income country (LMIC) hospitals in multicenter orthopaedic trials expands the pool of eligible patients and improves the external validity of the evidence. Furthermore, promoting studies in LMIC hospitals defines the optimal treatments for low-resource settings, the conditions under which the majority of musculoskeletal injuries are treated. The objective of this study was to determine the feasibility of a randomized controlled trial comparing external fixation with intramedullary (IM) nailing in patients with an isolated open tibial fracture who presented to a regional hospital in Uganda.

METHODS

From July 2016 to July 2017, skeletally mature patients who presented to a Ugandan regional hospital with an isolated Gustilo-Anderson type-II or IIIA open fracture of the tibial shaft were eligible for inclusion. The primary feasibility outcomes were the enrollment rate, the recruitment rate, and the 3 and 12-month follow-up rates. The secondary outcomes included a comparison of 3 and 12-month follow-up rates between the treatment arms and a qualitative assessment of barriers to enrollment, timely treatment, and missed follow-up.

RESULTS

During the 12-month enrollment period, 37.5% (30 of 80) of eligible patients were successfully enrolled and operatively treated on the basis of their random allocation, with an enrollment rate of 2.5 patients per month. Of the 30 enrolled patients, 53% completed their 3-month follow-up appointment, and 40% completed their 1-year follow-up appointment. Rates of 1-year follow-up were significantly higher for patients receiving IM nails than for those receiving external fixation (absolute difference, 52%; 95% confidence interval [CI], 21 to 83, p < 0.01). The main reasons that patients declined to participate in the trial were preferences for treatment by traditional bonesetters and prehospital delays that were related to a disorganized referral system. Barriers to follow-up included prohibitive transportation costs and community pressure to turn to traditional forms of treatment.

CONCLUSIONS

A regional hospital in Uganda can successfully enroll, randomize, and operatively treat multiple patients with an open tibial fracture each month. Patient follow-up presents substantial concerns over trial feasibility in this setting. Cultural pressure to utilize traditional treatments remains a particularly common barrier to study-participant enrollment and retention.

The TEAM (Trauma Evaluation and Management) course: medical student knowledge gains and retention in the USA versus Ghana

INTRODUCTION

Trauma and injury are significant contributors to the global burden of disease, with 5 million deaths and 250 million disability-adjusted life years lost in 2015. This burden is disproportionally borne by low- and middle-income countries (LMICs). Solutions are complex, but one area for improvement is basic trauma education. The American College of Surgeons has developed the Trauma Evaluation and Management (TEAM) course as an introduction to trauma care for medical students. We hypothesized that the TEAM course would be an effective educational program in LMICs and result in increased knowledge gains and retention similar to students in high-income countries (HICs).

METHODS

The TEAM course was taught and students evaluated at two sites, one LMIC (Ghana) and one HIC (USA), after obtaining approval from the HIC Institutional Review Board and medical schools at both sites. Participation was optional for all students and results were de-identified. The course was administered by a single educator for all sessions. Multiple-choice exams were given before and after the course, and again 6 months later.

RESULTS

A total of 62 LMIC and 64 HIC students participated in the course and completed initial testing. Demographics for the two groups were similar, as was participant attrition over time. LMIC students started with a relative knowledge deficit, scoring lower on both pre-course and post-course tests than HIC students, but gained more knowledge during the initial teaching session. After 6 months, the LMIC students continued to improve, whereas the HIC students' knowledge had regressed. Most students recommended course expansion.

CONCLUSION

The TEAM course is a useful tool to provide the basic principles of trauma care to students in LMICs, and should be expanded. Further study is needed to determine the impact of TEAM education on patient care in LMICs.

LEVEL OF EVIDENCE

Level III; Care Management.

Informing prehospital care planning using pilot trauma registry data in Yaoundé, Cameroon

INTRODUCTION

About 54% of deaths in low- and middle-income countries (LMICs) are attributable to lack of prehospital care. The single largest contributor to the disability-adjusted life years due to poor prehospital care is injury. Despite having disproportionately high injury burdens, most LMIC trauma systems have little prehospital organization. An understanding of existing prehospital care patterns in LMICs is warranted as a precursor to strengthening prehospital systems.

METHODS

In this retrospective pilot study, we collected demographic and injury characteristics, therapeutic itinerary, and transport data of patients that were captured by the trauma registry at the Central Hospital of Yaoundé (CHY) from April 15, 2009 to October 15, 2009. Bivariate and multivariate regression analyses were used to explore relationships between care-seeking behavior, method of transport, and predictor variables.

RESULTS

The mean age was 30.2 years (95% CI [29.7, 30.7]) and 73% were male. Therapeutic itinerary was available for 97.5% of patients (N = 2855). Nearly 18.7% of patients sought care elsewhere before CHY and 82% of such visits were at district hospitals or health clinics. Moderately (OR 1.336, p = 0.009) and severely (OR 1.605, p = 0.007) injured patients were more likely to seek care elsewhere before CHY and were less likely to be discharged home after their emergency ward visit as opposed to being admitted to the hospital for further treatment (OR 0.462, p < 0.001). Commercial vehicles provided most prehospital transport (65%), while police or ambulance transported few injured patients (7%).

CONCLUSIONS

Possible areas for prehospital trauma care strengthening include training lay commercial vehicle drivers in trauma care and formalizing triage, referral, and communication protocols for prehospital care to optimize timely transfer and care while minimizing secondary injury to patients.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District

Importance

In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning.

Objective

To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda.

Design, Setting, and Participants

A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined.

Main Outcomes and Measures

The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design.

Results

Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital.

Conclusions and Relevance

The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.

Exploring data sources for road traffic injury in Cameroon: Collection and completeness of police records, newspaper reports, and a hospital trauma registry

BACKGROUND

Road traffic injury surveillance systems are a cornerstone of organized efforts at injury control. Although high-income countries rely on established trauma registries and police databases, in low- and middle-income countries, the data source that provides the best collection of road traffic injury events in specific low- and middle-income country contexts without mature surveillance systems is unclear. The objective of this study was to compare the information available on road traffic injuries in 3 data sources used for surveillance in the sub-Saharan African country of Cameroon, providing potential insight on data sources for road traffic injury surveillance in low- and middle-income countries. We assessed the number of events captured and the information available in Yaoundé, Cameroon, from 3 separate sources of data on road traffic injuries: trauma registry, police records, and newspapers.

METHODS

Data were collected from a single-hospital trauma registry, police records, and the 6 most widely circulated newspapers in Yaoundé during a 6-month period in 2009. The number of road traffic injury events, mortality, and other variables included commonly in injury surveillance systems were recorded. We compared these sources using descriptive analysis.

RESULTS

Hospital, police, and newspaper sources recorded 1,686, 273, and 480 road traffic injuries, respectively. The trauma registry provided the most complete data for the majority of variables explored; however, the newspaper data source captured 2, mass casualty, train crash events unrecorded in the other sources. Police data provided the most complete information on first responders to the scene, missing in only 7%.

CONCLUSION

Investing in the hospital-based trauma registry may yield the best surveillance for road traffic injuries in some low- and middle-income countries, such as Yaoundé, Cameroon; however, police and newspaper reports may serve as alternative data sources when specific information is needed.

Pediatric First Aid Practices in Ghana: A Population-Based Survey

INTRODUCTION

Children in low- and middle-income countries (LMIC) often receive care outside the formal medical sector. Improving pre-hospital first aid has proven to be highly cost-effective in lowering trauma mortality. Few studies in LMIC have examined home first aid practices for injured children.

METHODS

We conducted a representative population-based survey of 200 caregivers of children under 18 years of age, representing 6520 households. Caregivers were interviewed about their first aid practices and care-seeking behaviors when a child sustained an injury at home. Injuries of interest included burns, lacerations, fractures and choking. Reported practices were characterized as recommended, low-risk, and potentially harmful.

RESULTS

For common injuries, 75-96% of caregivers reported employing a recommended practice (e.g., running cool water over a burn injury). However, for these same injuries, 13-61% of caregivers also identified potentially harmful management strategies (e.g., applying sand to a laceration). Choking had the highest proportion (96%) of recommended first aid practice: (e.g., hitting the child's back) and the lowest percent (13%) of potentially harmful practices (e.g., attempting manual removal). Fractures had the lowest percent (75%) of recommended practices (e.g., immediately bringing the child to a health facility). Burns had the highest percent (61%) of potentially harmful practices (e.g., applying kerosene).

CONCLUSIONS

While most caregivers were aware of helpful first aid practices to administer for a child injury, many parents also described potentially harmful practices or delays in seeking medical attention. As parents are the de facto first responders to childhood injury, there are opportunities to strengthen pre-hospital care for children in LMICs.

The burden of trauma in four rural district hospitals in Malawi: a retrospective review of medical records

BACKGROUND

Few injury surveillance systems collect data in sub-Saharan Africa. This medical record review of four rural hospitals provides baseline data on the burden of trauma in Malawi.

METHODS

We reviewed all outpatient, inpatient, and mortuary records for one full year at four of the 28 district hospitals in Malawi: Dedza in central Malawi, Mangochi in the east, Nkhata Bay in the north, and Thyolo in the south. We used descriptive and comparative statistics to examine characteristics of patients and the data file.

RESULTS

During 2012, 18,735 trauma patients were treated at the four district hospitals. Trauma cases accounted for 3.5% of the 541,170 patient visits. In total, 60.8% of trauma patients were male; 39.1% were 0–14 years old and 50.4% were 15–49 years old. The logbooks were missing information about the primary type of injury for 44.9% of patients and about injury cause for 82.7%. Of the recorded trauma diagnoses, the most common injuries were soft tissue injuries, fractures, and sprains. The most commonly reported causes of injuries were animal bites (mostly dog bites), road traffic injuries, assaults, burns, and falls.

CONCLUSIONS

The development and implementation of improved methods for acquiring more complete, accurate, and useful trauma data in Malawi and other low-income countries requires addressing difficulties that might result in missing data. Increased injury surveillance is critical for improving trauma care and meeting the emerging global demand for burden of disease data.

Road traffic injuries in Yaoundé, Cameroon: A hospital-based pilot surveillance study

BACKGROUND

Road traffic injuries (RTIs) are a major cause of death and disability worldwide. In Cameroon, like the rest of sub-Saharan Africa, more data on RTI patterns and outcomes are needed to improve treatment and prevention. This study analyses RTIs seen in the emergency room of the busiest trauma centre in Yaoundé, Cameroon.

METHODS

A prospective injury surveillance study was conducted in the emergency room of the Central Hospital of Yaoundé from April 15 to October 15, 2009. RTI patterns and relationships among demographic variables, road collision characteristics, injury severity, and outcomes were identified.

RESULTS

A total of 1686 RTI victims were enrolled. The mean age was 31 years, and 73% were male. Eighty-eight percent of road collisions occurred on paved roads. The most common user categories were 'pedestrian' (34%) and 'motorcyclist' (29%). Pedestrians were more likely to be female (p<0.001), while motorcyclists were more likely to be male (p<0.001). Injuries most commonly involved the pelvis and extremities (43%). Motorcyclists were more likely than other road users to have serious injuries (RR=1.45; 95% CI: 1.25, 1.68). RTI victims of lower economic status were more likely to die than those of higher economic status.

DISCUSSION

Vulnerable road users represent the majority of RTI victims in this surveillance study. The burden of RTI on hospitals in Cameroon is high and likely to increase. Data on RTI victims who present to trauma centres in low- and middle-income countries are essential to improving treatment and prevention.

Use of healthcare services by injured people in Khartoum State, Sudan

Background

Trauma care is an important factor in preventing death and reducing disability. Injured persons in low- and middle-income countries are expected to use the formal healthcare system in increasing numbers. The objective of this paper is to examine use of healthcare services after injury in Khartoum State, Sudan.

Methods

A community-based survey using a stratified two-stage cluster sampling technique in Khartoum State was performed. Information on healthcare utilisation was taken from injured people. A logistic regression analysis was used to explore factors affecting the probability of using formal healthcare services.

Results

During the 12 months preceding the survey a total of 441 cases of non-fatal injuries occurred, with 260 patients accessing formal healthcare. About a quarter of the injured persons were admitted to hospital. Injured people with primary education were less likely to use formal healthcare compared to those with no education. Formal health services were most used by males and in cases of road traffic injuries. The lowest socio-economic strata were least likely to use formal healthcare.

Conclusions

Public health measures and social security should be strengthened by identifying other real barriers that prevent low socio-economic groups from making use of formal healthcare facilities. Integration and collaboration with traditional orthopaedic practitioners are important aspects that need further attention.

Emergency response in resource-poor settings: a review of a newly-implemented EMS system in rural Uganda

INTRODUCTION

The goal of an Emergency Medical Services (EMS) system is to prevent needless death or disability from time-sensitive disease processes. Despite growing evidence that these processes contribute significantly to mortality in low- and middle- income countries (LMICs), there has been little focus on the development of EMS systems in poor countries. Problem The objective of this study was to understand the utilization pattern of a newly-implemented EMS system in Ruhiira, Uganda.

METHODS

An EMS system based on community priorities was implemented in rural Uganda in 2009. Six months of ambulance logs were reviewed. Patient, transfer, and clinical data were extracted and analyzed.

RESULTS

In total, 207 cases were reviewed. Out of all transfers, 66% were for chief complaints that were obstetric related, while 12% were related to malaria. Out of all activations, 77.8% were for female patients. Among men, 34% and 28% were related to malaria and trauma, respectively. The majority of emergency transfers were from district to regional hospitals, including 52% of all obstetric transfers, 65% of malaria transfers, and 62% of all trauma transfers. There was no significant difference in the call to arrival on scene time, the time to scene or the scene to treatment time during the day and night (P > .05). Cost-benefit analysis revealed a cost of $89.95 per life saved with an estimated $0.93/capita to establish the system and $0.09/capita/year to maintain the system.

CONCLUSION

Contrary to current belief, EMS systems in rural Africa can be affordable and highly utilized, particularly for life-threatening, nontrauma complaints. Construction of a simple but effective EMS system is feasible, acceptable, and an essential component to the primary health care system of LMICs.

Hospital-based injury data from level III institution in Cameroon: retrospective analysis of the present registration system

BACKGROUND

Data on the epidemiology of trauma in Cameroon are scarce. Presently, hospital records are still used as a primary source of injury data. It has been shown that trauma registries could play a key role in providing basic data on trauma. Our goal is to review the present emergency ward records for completeness of data and provide an overview of injuries in the city of Limbe and the surrounding area in the Southwest Region of Cameroon prior to the institution of a formal registration system.

METHODS

A retrospective review of Emergency Ward logs in Limbe Hospital was conducted over one year. Records for all patients over 15 years of age were reviewed for 14 data points considered to be essential to a basic trauma registry. Completeness of records was assessed and a descriptive analysis of patterns and trends of trauma was performed.

RESULTS

Injury-related conditions represent 27% of all registered admissions in the casualty department. Information on age, sex and mechanism of injury was lacking in 22% of cases. Information on vital signs was present in 2% (respiratory rate) to 12% (blood pressure on admission) of records. Patient disposition (admission, transfer, discharge, or death) was available 42% of the time, whilst location of injury was found in 84% of records. Road traffic injury was the most frequently recorded mechanism (36%), with the type of vehicle specified in 54% and the type of collision in only 22% of cases. Intentional injuries were the second most frequent mechanism at 23%.

CONCLUSION

The frequency of trauma found in this context argues for further prevention and treatment efforts. The institution of a formal registration system will improve the completeness of data and lead to increased ability to evaluate the severity and subsequent public health implications of injury in this region.

Identifying barriers to emergency care services

OBJECTIVE

This paper aims to present a review of published evidence of barriers to emergency care, with attention towards both financial and other barriers.

METHOD

With the keywords (financial) accessibility, barriers and emergency care services, citations in PubMed were searched and further selected in the context of the objective of this article.

RESULTS

Forty articles, published over a period of 15 years, showed evidence of significant barriers to emergency care. These barriers often tend to persist, despite the fact that the evidence was published many years ago. Several publications stressed the importance of the financial barriers in foregoing or delaying potentially life-saving emergency services, both in poor and rich countries. Other publications report non-financial barriers that prevent patients in need of emergency care (pre-hospital and in-patient care) from seeking care, from arriving in the proper emergency department without undue delay or from receiving proper treatment when they do arrive in these departments.

CONCLUSION

It is clear that timely access to life-saving and disability-preventing emergency care is problematic in many settings. Yet, low-cost measures can likely be taken to significantly reduce these barriers. It is time to make an inventory of these measures and to implement the most cost-effective ones worldwide.

Does socio-economic status explain use of modern and traditional health care services?

Although socioeconomic status is acknowledged to be an important determinant of modern health care utilisation, most analyses to date have failed to include traditional systems as alternative, or joint, providers of care. In developing countries, where pluralistic care systems are common, individuals are likely to be using multiple sources of health care, and the order in which systems are chosen is likely to vary according to income. This paper uses self-collected data from households in Ghana and econometric techniques (biprobit modelling and ordered logit) to show that rising income is associated with modern care use whilst decreasing income is associated with traditional care use. When utilisation is analysed in order, results show rising income to have a positive effect on choice of modern care as a first provider, whilst choosing it second, third or never is associated with decreasing income. The effects of income on utilisation patterns of traditional care are stronger: as income rises, utilisation of traditional care as a first choice decreases. Policy should incorporate traditional care into the general utilisation framework and recognise that strategies which increase income may encourage wider utilisation of modern over traditional care, whilst high levels of poverty will see continued use of traditional care.

Non-Doctors as Trauma Surgeons? A Controlled Study of Trauma Training for Non-Graduate Surgeons in Rural Cambodia

Introduction:

Due to the accelerating global epidemic of trauma, efficient and sustainable models of trauma care that fit low-resource settings must be developed. In most low-income countries, the burden of surgical trauma is managed by non-doctors at local district hospitals.

Objective:

This study examined whether it is possible to establish primary trauma surgical services of acceptable quality at rural district hospitals by systematically training local, non-graduate, care providers.

Methods:

Seven district hospitals in the most landmine-infested provinces of Northwestern Cambodia were selected for the study. The hospitals were referral points in an established prehospital trauma system. During a four-year training period, 21 surgical care providers underwent five courses (150 hours total) focusing on surgical skills training. In-hospital trauma deaths and postoperative infections were used as quality-of care indicators. Outcome indicators during the training period were compared against pre-intervention data.

Results:

Both the control and treatment populations had long prehospital transport times (three hours) and were severely injured (median Injury Severity Scale Score = 9). The in-hospital trauma fatality rate was low in both populations and not significantly affected by the intervention. The level of post-operative infections was reduced from 22% to 10.3% during the intervention (95% confidence interval for difference 2.8–20.2%). The trainees' selfrating of skills (Visual Analogue Scale) before and after the training indicated a significantly better coping capacity.

Conclusions:

Where the rural hospital is an integral part of a prehospital trauma system, systematic training of non-doctors improves the quality of trauma surgery. Initial efforts to improve trauma management in low-income countries should focus on the district hospital.

An estimate of the number of lives that could be saved through improvements in trauma care globally

BACKGROUND

Reducing the global burden of injury requires both injury prevention and improved trauma care. We sought to provide an estimate of the number of lives that could be saved by improvements in trauma care, especially in low income and middle income countries.

METHODS

Prior data showed differences in case fatality rates for seriously injured persons (Injury Severity Score ≥ 9) in three separate locations: Seattle, WA (high income; case fatality 35%); Monterrey, Mexico (middle income; case fatality 55%); and Kumasi, Ghana (low income; case fatality 63%). For the present study, total numbers of injury deaths in all countries in different economic strata were obtained from the Global Burden of Disease study. The number of lives that could potentially be saved from improvements in trauma care globally was calculated as the difference in current number of deaths from trauma in low income and middle income countries minus the number of deaths that would have occurred if case fatality rates in these locations were decreased to the case fatality rate in high income countries.

RESULTS

Between 1,730,000 and 1,965,000 lives could be saved in low income and middle income countries if case fatality rates among seriously injured persons could be reduced to those in high income countries. This amounts to 34-38% of all injury deaths.

CONCLUSIONS

A significant number of lives could be saved by improvements in trauma care globally. This is another piece of evidence in support of investment in and greater attention to strengthening trauma care services globally.

Pediatric trauma care in Africa: the evolution and challenges

Childhood trauma is one of the major health problems in the world. Although pediatric trauma is a global phenomenon in low- and middle-income countries, sub-Saharan countries are disproportionally affected. We reviewed the available literature relevant to pediatric trauma in Africa using the MEDLINE database, local libraries, and personal contacts. A critical review of all cited sources was performed with an emphasis on the progress made over the past decades as well as the ongoing challenges in the prevention and management of childhood trauma. After discussing the epidemiology and spectrum of pediatric trauma, we focus on the way forward to reduce the burden of childhood injuries and improve the management and outcome of injured children in Africa.

Bypassing proximal health care facilities for acute care: a survey of patients in a Ghanaian Accident and Emergency Centre

OBJECTIVE

To characterise the population that presents to the Accident and Emergency Centre (AEC) at Komfo Anokye Teaching Hospital (KATH) and to identify risk factors associated with bypassing proximal care facilities.

METHODS

A structured questionnaire was verbally administered to patients presenting to the AEC over 2 weeks. The questionnaire focused on the use of health care resources and characteristics of current illness or injury. Measures recorded include demographics, socioeconomic status, chief complaint, transportation and mobility, reasons for choosing KATH and health care service utilisation and cost.

RESULTS

The total rate of bypassing proximal care was 33.9%. On multivariate analysis, factors positively associated with bypassing included age older than 38 years (OR: 2.18, P 0.04) and prior visits to facility (OR 2.88, P 0.01). Bypassers were less likely to be insured (OR 0.31, P 0.01), to be seeking care due to injury (OR 0.42, P 0.03) and to have previously sought care for the problem (OR 0.10, P < 0.001).

CONCLUSIONS

Patients who bypass facilities near them to seek care at an urban AEC in Ghana do so for a combination of reasons including familiarity with the facility, chief complaint and insurance status. Understanding bypassing behaviour is important for guiding health care utilisation policy decisions and streamlining cost-effective, appropriate access to care for all patients.

Placing emergency care on the global agenda

Emergency care serves a key function within health care systems by providing an entry point to health care and by decreasing morbidity and mortality. Although primarily focused on evaluation and treatment for acute conditions, emergency care also serves as an important locus of provision for preventive care with regard to injuries and disease progression. Despite its important and increasing role, however, emergency care has been frequently overlooked in the discussion of health systems and delivery platforms, particularly in developing countries. Little research has been done in lower- and middle-income countries on the burden of disease reduction attributable to emergency care, whether through injury treatment and prevention, urgent and emergency treatment of acute conditions, or emergency treatment of complications from chronic conditions. There is a critical need for research documenting the role of emergency care services in reducing the global burden of disease. In addition to applying existing methodologies toward this aim, new methodologies should be developed to determine the cost-effectiveness of these interventions and how to effectively cover the costs of and demands for emergency care needs. These analyses could be used to emphasize the public health and clinical importance of emergency care within health systems as policymakers determine health and budgeting priorities in resource-limited settings.

The "other" neglected diseases in global public health: surgical conditions in sub-Saharan Africa

Doruk Ozgediz and Robert Riviello discuss the burden of premature death and disability and the economic burden of surgical conditions in Africa.

Medical rehabilitation in Ghana

PURPOSE

To explore the current system of medical rehabilitation services for persons with disabilities in a developing country (Ghana) and to identify future needs, opportunities, and barriers.

METHODS

Information was obtained through a literature review and through interviews with healthcare providers, disabled people's organizations, educators, government officials, and consumers. Direct observations were made of Ghana's capital city, Accra, and of a major tertiary medical center there, Korle Bu Teaching Hospital.

RESULTS

Ghana has virtually no medical rehabilitation and few laws to protect the disabled. There are no occupational therapists or physiatrists in the entire country, and only a handful of physical therapists, prosthetists, orthotists, and speech therapists. There are many barriers to the establishment of such services, including lack of funding, limited government support, cultural stigma of the disabled and poor utilization of existing resources.

CONCLUSIONS

A national model for sustainable medical rehabilitation is needed in Ghana and likely in other similar countries.

Characteristics of non-fatal injuries in Leon, Nicaragua – 2004

This article describes the epidemiology of injuries collected in the Injury Surveillance System in Leon Hospital in Nicaragua. A total of 6659 persons were treated for injuries in 2004. It was discovered that 88% of all injuries were unintentional, 9% involved interpersonal violence, 2% were self-inflicted and 0.2% was undetermined. Men accounted for 64.7% of the cases, with the highest rate among 20 - 24 year olds (5625.8 per 100,000 inhabitants). Among women, the highest rate was in those aged 64 years and older (5324.2 per 100 000 inhabitants). The most common mechanisms were falls (33.9%), blunt force (26.8%), cut/pierce/stab (15.1%) and transportation-related (12.8%). These results indicate the need to identify prevention strategies for those injuries that were most commonly treated in emergency, such as unintentional falls among older women, self-inflicted poisoning among young women and blunt force and transportation-related injuries among young men.

Utilization of health services by the injured residents in Kumasi, Ghana

The objective was to determine the pattern of health service utilization by the injured in Kumasi, Ghana and thus to gain information useful for the strengthening of trauma care in that environment. A household survey was utilized as it was anticipated that many injured might not receive formal medical care and a total of 11,663 persons living in 264 clusters in Kumasi were surveyed. One-third of all injured did not receive any formal medical care, mainly due to financial constraints. Altogether, 37% of the injured attended a hospital and 34% attended a clinic. Among the severely injured (> or =1 month disability) attending a clinic, most (76%) used it as the sole source of care. Most (54%) of these clinics were private. Efforts to strengthen trauma care in urban Africa need to address financial barriers to care and need to consider clinics, as well as the main hospitals.

Emergency medical services in Islamabad, Pakistan: a public-private partnership

OBJECTIVES

The objective of this study was to evaluate the emergency medical services (EMS) based in Islamabad, Pakistan. Rescue-15 is an innovative EMS collaboration project between the police, the private sector and the community.

METHODS

Data from Rescue-15 were used for systems analysis. The institutional set-up, private-public partnership, client satisfaction and sustainability issues were examined. The access and efficiency of EMS were assessed in terms of ambulance response time.

RESULTS

Primarily, systems analysis showed community participation to explain the project's strength. Since its establishment, the project has been meeting its own recurrent expenditures without levying an extra burden on the Government. Sustainability issues such as amendments to legislation have been addressed at departmental and governmental levels. Data analysis showed that rescue time is, on average, 10.4 min (SD=2.6 min). A client survey also demonstrated user satisfaction and increased confidence in the service.

CONCLUSIONS

This EMS programme exemplifies the potential of public-private partnership involving the police and the private sector in project implementation and management in a developing country with scarce resources. This initiative to involve the public and the private sector may provide a model for implementation of such services in other resource-poor developing countries, which may in turn facilitate realistic solutions for better prehospital care in developing countries.