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Macharia PM, Wong KLM, Beňová L, Wang J, Makanga PT, Ray N, Banke-Thomas A. Measuring geographic access to emergency obstetric care: a comparison of travel time estimates modelled using Google Maps Directions API and AccessMod in three Nigerian conurbations. GEOSPATIAL HEALTH 2024; 19. [PMID: 38801322 DOI: 10.4081/gh.2024.1266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
Google Maps Directions Application Programming Interface (the API) and AccessMod tools are increasingly being used to estimate travel time to healthcare. However, no formal comparison of estimates from the tools has been conducted. We modelled and compared median travel time (MTT) to comprehensive emergency obstetric care (CEmOC) using both tools in three Nigerian conurbations (Kano, Port-Harcourt, and Lagos). We compiled spatial layers of CEmOC healthcare facilities, road network, elevation, and land cover and used a least-cost path algorithm within AccessMod to estimate MTT to the nearest CEmOC facility. Comparable MTT estimates were extracted using the API for peak and non-peak travel scenarios. We investigated the relationship between MTT estimates generated by both tools at raster celllevel (0.6 km resolution). We also aggregated the raster cell estimates to generate administratively relevant ward-level MTT. We compared ward-level estimates and identified wards within the same conurbation falling into different 15-minute incremental categories (<15/15-30/30-45/45-60/+60). Of the 189, 101 and 375 wards, 72.0%, 72.3% and 90.1% were categorised in the same 15- minute category in Kano, Port-Harcourt, and Lagos, respectively. Concordance decreased in wards with longer MTT. AccessMod MTT were longer than the API's in areas with ≥45min. At the raster cell-level, MTT had a strong positive correlation (≥0.8) in all conurbations. Adjusted R2 from a linear model (0.624-0.723) was high, increasing marginally in a piecewise linear model (0.677-0.807). In conclusion, at <45-minutes, ward-level estimates from the API and AccessMod are marginally different, however, at longer travel times substantial differences exist, which are amenable to conversion factors.
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Affiliation(s)
- Peter M Macharia
- Population and Health Impact Surveillance Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Department of Public Health, Institute of Tropical Medicine, Antwerp.
| | - Kerry L M Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London.
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London.
| | - Jia Wang
- School of Computing and Mathematical Sciences, University of Greenwich, London.
| | - Prestige Tatenda Makanga
- Surveying and Geomatics Department, Midlands State University Faculty of the Built Environment, Gweru, Midlands, Zimbabwe; Climate, Environment and Health Department, Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool.
| | - Nicolas Ray
- GeoHealth Group, Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Institute for Environmental Sciences, University of Geneva, Geneva.
| | - Aduragbemi Banke-Thomas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; School of Human Sciences, University of Greenwich, London, United Kingdom; Maternal and Reproductive Health Research Collective, Surulere, Lagos.
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Whitaker J, Edem I, Togun E, Amoah AS, Dube A, Chirwa L, Munthali B, Brunelli G, Van Boeckel T, Rickard R, Leather AJM, Davies J. Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi. PLoS Med 2024; 21:e1004344. [PMID: 38252654 PMCID: PMC10843098 DOI: 10.1371/journal.pmed.1004344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/05/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
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.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Idara Edem
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | - Ella Togun
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Abena S. Amoah
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
- School of Medicine & Oral Health, Department of Pathology, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
| | - Giulia Brunelli
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
| | - Thomas Van Boeckel
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
- Center for Disease Dynamics Economics and Policy, Washington, DC, United States of America
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Andrew JM Leather
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Ashraf MN, Fatima I, Muhammad AA, Albutt K, Pigeolet M, Latif A, Meara JG, Samad L. Estimating access to surgical care: A community centered national household survey from Pakistan. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002130. [PMID: 37967062 PMCID: PMC10651040 DOI: 10.1371/journal.pgph.0002130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.
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Affiliation(s)
- Muhammad Nabeel Ashraf
- Indus Hospital and Health Network, Karachi, Pakistan
- Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Irum Fatima
- Interactive Research and Development (IRD), Karachi, Pakistan
| | | | | | - Manon Pigeolet
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Université Libre de Bruxelles, Faculty of Medicine, Brussels, Belgium
| | - Asad Latif
- Department of Anaesthesia, Aga Khan University, Karachi, Pakistan
| | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA, United States of America
| | - Lubna Samad
- Interactive Research and Development (IRD) Global, Singapore, Singapore
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McCormick I, Nesemann JM, Zhao J, Mdala S, Kitema GF, Mwangi N, Gichangi M, Tang K, Burton MJ, Ramke J. Travel time to cataract surgical services in Kenya, Malawi and Rwanda: demonstrating a standardised indicator of physical access to cataract surgery. Eye (Lond) 2023:10.1038/s41433-023-02790-8. [PMID: 37853109 DOI: 10.1038/s41433-023-02790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Travel time can be used to assess health services accessibility by reflecting the proximity of services to the people they serve. We aimed to demonstrate an indicator of physical access to cataract surgery and identify subnational locations where people were more at risk of not accessing cataract surgery. METHODS We used an open-access inventory of public health facilities plus key informants in Kenya, Malawi and Rwanda to compile a geocoded inventory of cataract facilities. For each country, gridded estimates of the population aged ≥ 50 years and a travel-time friction surface were combined and a least-cost-path algorithm applied to estimate the shortest travel time between each grid and the nearest cataract facility. We categorised continuous travel time by 1-, 2- and 3 h thresholds and calculated the proportion of the population in each category. RESULTS At the national level, the proportion of the population aged ≥ 50 years within 2 h travel time to permanent cataract surgical services was 97.2% in Rwanda (n = 10 facilities), 93.5% in Kenya (n = 74 facilities) and 92.0% in Malawi (n = 6 facilities); this reduced to 77.5%, 84.1% and 52.4% within 1 h, respectively. The least densely populated subnational regions had the poorest access to cataract facilities in Malawi (0.0%) and Kenya (1.9%). CONCLUSION We demonstrated an indicator of access that reflects the distribution of the population at risk of age-related cataract and identifies regions that could benefit from more accessible services. This indicator provides additional demand-side context for eye health planning and supports WHO's goal of advancing integrated people-centred eye care.
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Affiliation(s)
- Ian McCormick
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - John M Nesemann
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- University of California San Francisco, Department of Ophthalmology, San Francisco, CA, USA
| | - Jinfeng Zhao
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Shaffi Mdala
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Gatera Fiston Kitema
- Ophthalmology Department, School of Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Michael Gichangi
- Ophthalmic Services Unit, Kenya Ministry of Health, Nairobi, Kenya
| | - Kevin Tang
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
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Miller H, Rudolfson N, Nkurunziza T, Cherian T, Kayitesi D, Mazimpaka C, Kateera F, Riviello R, Hedt-Gauthier B. Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda. Pan Afr Med J 2023; 46:30. [PMID: 38107338 PMCID: PMC10724031 DOI: 10.11604/pamj.2023.46.30.25504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/01/2020] [Indexed: 12/19/2023] Open
Abstract
Introduction timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. Methods this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. Results the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. Conclusion in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.
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Affiliation(s)
- Hillary Miller
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
| | - Niclas Rudolfson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Word Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund University, Lund, Sweden
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
| | - Theoneste Nkurunziza
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
- Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
| | | | | | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
- Center for Surgery and Public Health, Brigham and Women´s Hospital, Boston, United States of America
| | - Bethany Hedt-Gauthier
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
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Lindert J, Bbaale D, Mohr C, Chamania S, Bandyopadhyay S, Boettcher J, Katabogama JB, Alliance BW, Elrod J. State of burns management in Africa: Challenges and solutions. Burns 2023; 49:1028-1038. [PMID: 36759220 DOI: 10.1016/j.burns.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Understand the availability of human resources, infrastructure and medical equipment and perceived improvement helps to address interventions to improve burn care. METHODS Online survey covering human resources, infrastructure, and medical equipment of burn centers as well as perceived challenges and points for improvement. The survey was distributed in English and French via snowball method. Descriptive statistics and AI-based technique random forest analysis was applied to identify determinants for a reduction of the reported mortality rate. RESULTS 271 questionnaires from 237 cities in 40 African countries were analyzed. 222 (81.9 %) from countries with a very low Human Development Index (HDI) (4th quartile). The majority (154, 56.8 %) of all responses were from tertiary health care facilities. In only 18.8 % (n = 51) therapy was free of charge for the patients. The majority (n = 131, 48.3 %) had between 1 and 3 specialist doctors (n = 131, 48.3 %), 1 to 3 general doctors (n = 138, 50.9 %) and more than 4 nurses (n = 175, 64.6 %). A separate burn ward was available in 94 (34.7 %) centers. Regular skin grafting was performed in 165 (39.1 %) centers. Random forest-based analysis revealed a significant association between HDI (feature importance: 0.38) and mortality. The most important reason for poor outcome was perceived late presentation (212 institutions, 78.2 %). The greatest perceived potential for improvement was introduction of intensive care units (229 institutions, 84.5 %), and prevention or education (227 institutions, 83.7 %). INTERPRETATION A variety of factors, including a low HDI, delayed hospital presentation e.g. due to prior care by non-physicians and lack of equipment seem to worsen the outcome. Introduction of an intensive care unit and communal education are perceived to be important steps in improving health care in burns.
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Affiliation(s)
- Judith Lindert
- Department of Pediatric Surgery, University Hospital Rostock, Ernst-Heydemann Str 8, 18057 Rostock, Germany; German Society of Global and Tropical Surgery e.V., Germany
| | - Dorothy Bbaale
- Department of Surgery, International Hospital Kampala, Plot 4686 Barnabas Rd, Kampala, Uganda; CURE International, 70 Ionia Ave SW, Suite 200, Grand Rapids, MI 49503, United States
| | - Christoph Mohr
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Shobha Chamania
- Choithram Hospital and Research Centre, 14, Manik Bagh Rd, Indore, India
| | - Soham Bandyopadhyay
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Headington, Oxford OX3 9DU, United Kingdom
| | - Johannes Boettcher
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | | | - Bisimwa Wani Alliance
- Provincial General Reference Hospital of Bukavu, 02, avenue Michombero/Commune de Kadutu, Bukavu, Democratic Republic of the Congo
| | - Julia Elrod
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Mroz EJ, Willis T, Thomas C, Janes C, Singini D, Njungu M, Smith M. Impacts of seasonal flooding on geographical access to maternal healthcare in the Barotse Floodplain, Zambia. Int J Health Geogr 2023; 22:17. [PMID: 37525198 PMCID: PMC10391775 DOI: 10.1186/s12942-023-00338-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/12/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Seasonal floods pose a commonly-recognised barrier to women's access to maternal services, resulting in increased morbidity and mortality. Despite their importance, previous GIS models of healthcare access have not adequately accounted for floods. This study developed new methodologies for incorporating flood depths, velocities, and extents produced with a flood model into network- and raster-based health access models. The methodologies were applied to the Barotse Floodplain to assess flood impact on women's walking access to maternal services and vehicular emergency referrals for a monthly basis between October 2017 and October 2018. METHODS Information on health facilities were acquired from the Ministry of Health. Population density data on women of reproductive age were obtained from the High Resolution Settlement Layer. Roads were a fusion of OpenStreetMap and data manually delineated from satellite imagery. Monthly information on floodwater depth and velocity were obtained from a flood model for 13-months. Referral driving times between delivery sites and EmOC were calculated with network analysis. Walking times to the nearest maternal services were calculated using a cost-distance algorithm. RESULTS The changing distribution of floodwaters impacted the ability of women to reach maternal services. At the peak of the dry season (October 2017), 55%, 19%, and 24% of women had walking access within 2-hrs to their nearest delivery site, EmOC location, and maternity waiting shelter (MWS) respectively. By the flood peak, this dropped to 29%, 14%, and 16%. Complete inaccessibility became stark with 65%, 76%, and 74% unable to access any delivery site, EmOC, and MWS respectively. The percentage of women that could be referred by vehicle to EmOC from a delivery site within an hour also declined from 65% in October 2017 to 23% in March 2018. CONCLUSIONS Flooding greatly impacted health access, with impacts varying monthly as the floodwave progressed. Additional validation and application to other regions is still needed, however our first results suggest the use of a hydrodynamic model permits a more detailed representation of floodwater impact and there is great potential for generating predictive models which will be necessary to consider climate change impacts on future health access.
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Affiliation(s)
- Elizabeth Jade Mroz
- School of Geography and water@Leeds, University of Leeds, Leeds, LS2 9JT, UK.
| | - Thomas Willis
- School of Geography and water@Leeds, University of Leeds, Leeds, LS2 9JT, UK
| | - Chris Thomas
- Lincoln Centre for Water & Planetary Health, University of Lincoln, Lincoln, LN6 7DW, UK
| | - Craig Janes
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Douglas Singini
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Mwimanenwa Njungu
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| | - Mark Smith
- School of Geography and water@Leeds, University of Leeds, Leeds, LS2 9JT, UK
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Geospatial Analysis of Accessibility to Surgical Care, a Brazilian Local Perspective. World J Surg 2023; 47:887-894. [PMID: 36645425 DOI: 10.1007/s00268-023-06892-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Surgical care has been neglected and recently discussed by the World Health Organization as a necessary component of health care. Situations that distance individuals and medical services are of particular concern. We aim to estimate the distance a patient who lives in a municipality without a general surgeon would have to travel to access surgical care; and to describe the geographical distribution of the surgical workforce. METHODS We obtained the surgical data from DATASUS, from IBGE, the information regarding the classification of each municipality and its location, and FEPAM, the road network. We performed the geoprocessing analysis on QGIS and the statistical analysis on SPSS. RESULTS The Rio Grande do Sul state had 496 municipalities, of which 69.4% were rural, with a mean of 9.19 general surgeons per overall municipality. A total of 237 cities had no general surgeons, of which 89.45% were in rural ones. There was a significant difference in the number of surgeons per municipality between rural and urban ones. We found a mean of 22.09 surgeons per 100,000 population. The mean distance traveled by a patient to a municipality with general surgeons available was 30.25 km, with a minimum of 2.46 km and a maximum of 268.22 km. CONCLUSIONS Disparities are associated with the geospatial distribution of surgical care in the Rio Grande do Sul state. The surgical workforce and the distance a patient travels are irregular geographically. This study is the start of inspiring other similar studies about geospatial surgical analysis.
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Molenaar L, Hierink F, Brun M, Monet JP, Ray N. Travel scenario workshops for geographical accessibility modeling of health services: A transdisciplinary evaluation study. Front Public Health 2023; 10:1051522. [PMID: 36743157 PMCID: PMC9889992 DOI: 10.3389/fpubh.2022.1051522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023] Open
Abstract
Introduction Limited geographical access to quality Emergency Obstetric and Newborn Care (EmONC) is a major driver of high maternal mortality. Geographic access to EmONC facilities is identified by the global community as a critical issue for reducing maternal mortality and is proposed as a global indicator by the Ending Preventable Maternal Mortality (EPMM) initiative. Geographic accessibility models can provide insight into the population that lacks adequate access and on the optimal distribution of facilities and resources. Travel scenarios (i.e., modes and speed of transport) used to compute geographical access to healthcare are a key input to these models and should approximate reality as much as possible. This study explores strategies to optimize and harmonize knowledge elicitation practices for developing travel scenarios. Methods Knowledge elicitation practices for travel scenario workshops (TSW) were studied in 14 African and South-Asian countries where the United Nations Population Fund supported ministries of health and governments in strengthening networks of EmONC facilities. This was done through a mixed methods evaluation study following a transdisciplinary approach, applying the four phases of the Interactive Learning and Action methodology: exploration, in-depth, integration, and prioritization and action planning. Data was collected in November 2020-June 2021 and involved scoping activities, stakeholder identification, semi-structured interviews (N = 9), an evaluation survey (N = 31), and two co-creating focus group discussions (N = 8). Results Estimating realistic travel speeds and limited time for the workshop were considered as the largest barriers. The identified opportunities were inclusively prioritized, whereby preparation; a favorable composition of attendees; validation practices; and evaluation were anticipated to be the most promising improvement strategies, explaining their central place on the co-developed initial standard operating procedure (SOP) for future TSWs. Mostly extensive preparation-both on the side of the organization and the attendees-was anticipated to address nearly all of the identified TSW challenges. Conclusion This study showed that the different identified stakeholders had contradicting, complementing and overlapping ideas about strategies to optimize and harmonize TSWs. Yet, an initial SOP was inclusively developed, emphasizing practices for before, during and after each TSW. This SOP is not only relevant in the context of the UNFPA EmONC development approach, but also for monitoring the newly launched EPMM indicator and even in the broader field of geographic accessibility modeling.
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Affiliation(s)
- Lotte Molenaar
- Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland,GeoHealth Group, Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland,Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Fleur Hierink
- Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland,GeoHealth Group, Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland,*Correspondence: Fleur Hierink ✉
| | - Michel Brun
- Technical Division, United Nations Population Fund (UNFPA), New York, NY, United States
| | - Jean-Pierre Monet
- Technical Division, United Nations Population Fund (UNFPA), New York, NY, United States
| | - Nicolas Ray
- Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland,GeoHealth Group, Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
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10
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Adde HA, van Duinen AJ, Andrews BC, Bakker J, Goyah KS, Salvesen Ø, Sheriff S, Utam T, Yaskey C, Weiser TG, Bolkan HA. Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards. Br J Surg 2023; 110:169-176. [PMID: 36469530 PMCID: PMC10364551 DOI: 10.1093/bjs/znac377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures. CONCLUSION Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.
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Affiliation(s)
- Håvard A Adde
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Alex J van Duinen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Juul Bakker
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Kezelebah S Goyah
- Lifebox Foundation, Monrovia, Liberia.,F. J. Grante Memorial Hospital, Greenville, Liberia
| | - Øyvind Salvesen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Swaliho Sheriff
- Lifebox Foundation, Monrovia, Liberia.,Department of Surgery, Liberia Governmental Hospital, Tubmanburg, Liberia
| | - Terseer Utam
- Lifebox Foundation, Monrovia, Liberia.,Department of Surgery and Traumatology, Redemption Hospital, Monrovia, Liberia
| | | | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA.,Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California, USA.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK.,Lifebox Foundation, London, UK
| | - Håkon A Bolkan
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
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11
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Alemu SM, Tura AK, do Amaral GSG, Moughalian C, Weitkamp G, Stekelenburg J, Biesma R. How applicable is geospatial analysis in maternal and neonatal health in sub-Saharan Africa? A systematic review. J Glob Health 2022; 12:04066. [PMID: 35939400 PMCID: PMC9359463 DOI: 10.7189/jogh.12.04066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Sub-Saharan Africa (SSA) has the world's highest maternal and neonatal morbidity and mortality and has shown the slowest progress in reducing them. In addition, there is substantial inequality in terms of maternal and neonatal morbidity and mortality in the region. Geospatial studies can help prioritize scarce resources by pinpointing priority areas for implementation. This systematic review was conducted to explore the application of geospatial analysis to maternal and neonatal morbidity and mortality in SSA. Methods A systematic search of PubMed, SCOPUS, EMBASE, and Web of Science databases was performed. All observational and qualitative studies that reported on maternal or neonatal health outcomes were included if they used a spatial analysis technique and were conducted in a SSA country. After removing duplicates, two reviewers independently reviewed each study's abstract and full text for inclusion. Furthermore, the quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Finally, due to the heterogeneity of studies, narrative synthesis was used to summarize the main findings, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed to report the review results. A total of 56 studies were included in the review. Results We found that geospatial analysis was used to identify inequalities in maternal and neonatal morbidity, mortality, and health care utilization and to identify gaps in the availability and geographic accessibility of maternal health facilities. In addition, we identified a few studies that used geospatial analysis for modelling intervention areas. We also detected challenges and shortcomings, such as unrealistic assumptions used by geospatial models and a shortage of reliable, up-to-date, small-scale georeferenced data. Conclusions The use of geospatial analysis for maternal and neonatal health in SSA is still limited, and more detailed spatial data are required to exploit the potential of geospatial technologies fully.
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Affiliation(s)
- Sisay Mulugeta Alemu
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.,Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Gabriel S Gurgel do Amaral
- Department of Health Sciences, Community and Occupational Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Catherine Moughalian
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | - Gerd Weitkamp
- Department of Cultural Geography, Faculty of Spatial Sciences, University of Groningen, Groningen, the Netherlands
| | - Jelle Stekelenburg
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands.,Department Obstetrics & Gynaecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - Regien Biesma
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
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12
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Banke-Thomas A, Macharia PM, Makanga PT, Beňová L, Wong KLM, Gwacham-Anisiobi U, Wang J, Olubodun T, Ogunyemi O, Afolabi BB, Ebenso B, Omolade Abejirinde IO. Leveraging big data for improving the estimation of close to reality travel time to obstetric emergency services in urban low- and middle-income settings. Front Public Health 2022; 10:931401. [PMID: 35968464 PMCID: PMC9372297 DOI: 10.3389/fpubh.2022.931401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Maternal and perinatal mortality remain huge challenges globally, particularly in low- and middle-income countries (LMICs) where >98% of these deaths occur. Emergency obstetric care (EmOC) provided by skilled health personnel is an evidence-based package of interventions effective in reducing these deaths associated with pregnancy and childbirth. Until recently, pregnant women residing in urban areas have been considered to have good access to care, including EmOC. However, emerging evidence shows that due to rapid urbanization, this so called “urban advantage” is shrinking and in some LMIC settings, it is almost non-existent. This poses a complex challenge for structuring an effective health service delivery system, which tend to have poor spatial planning especially in LMIC settings. To optimize access to EmOC and ultimately reduce preventable maternal deaths within the context of urbanization, it is imperative to accurately locate areas and population groups that are geographically marginalized. Underpinning such assessments is accurately estimating travel time to health facilities that provide EmOC. In this perspective, we discuss strengths and weaknesses of approaches commonly used to estimate travel times to EmOC in LMICs, broadly grouped as reported and modeled approaches, while contextualizing our discussion in urban areas. We then introduce the novel OnTIME project, which seeks to address some of the key limitations in these commonly used approaches by leveraging big data. The perspective concludes with a discussion on anticipated outcomes and potential policy applications of the OnTIME project.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, United Kingdom
- Maternal and Reproductive Health Research Collective, Lagos, Nigeria
- *Correspondence: Aduragbemi Banke-Thomas
| | - Peter M. Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Prestige Tatenda Makanga
- Surveying and Geomatics Department, Faculty of Science and Technology, Midlands State University, Gweru, Zimbabwe
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kerry L. M. Wong
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Jia Wang
- School of Computing and Mathematical Sciences, University of Greenwich, London, United Kingdom
| | - Tope Olubodun
- Department of Community Medicine and Primary Care, Federal Medical Centre Abeokuta, Abeokuta, Nigeria
| | | | - Bosede B. Afolabi
- Maternal and Reproductive Health Research Collective, Lagos, Nigeria
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Bassey Ebenso
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Ibukun-Oluwa Omolade Abejirinde
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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13
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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14
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Bhangdia KP, Iyer HS, Joseph JP, Dorne RL, Mukherjee J, Fadelu T. Comparing absolute and relative distance and time travel measures of geographic access to healthcare facilities in rural Haiti. BMJ Open 2022; 12:e056123. [PMID: 35613799 PMCID: PMC9174809 DOI: 10.1136/bmjopen-2021-056123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION While travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals. METHODS Eight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti's section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests. RESULTS All five geographic access measures were highly correlated (range: 0.78-0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND. CONCLUSION While the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use.
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Affiliation(s)
- Kayleigh Pavitra Bhangdia
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Hari S Iyer
- Division of Population Science, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Joia Mukherjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Temidayo Fadelu
- Division of Population Science, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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15
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Fadelu T, Nadella P, Iyer HS, Uwikindi F, Shyirambere C, Manirakiza A, Triedman SA, Rebbeck TR, Shulman LN. Toward Equitable Access to Tertiary Cancer Care in Rwanda: A Geospatial Analysis. JCO Glob Oncol 2022; 8:e2100395. [PMID: 35623016 PMCID: PMC9225505 DOI: 10.1200/go.21.00395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/19/2022] [Indexed: 01/23/2023] Open
Abstract
PURPOSE Geographic access to care is an important measure of health equity. In this study, we describe geographic access to cancer care centers (CCCs) in Rwanda with the current facilities providing care and examine how access could change with expanded care infrastructure. METHODS Health facilities included are public hospitals administered by the Rwanda Ministry of Health. The WorldPop Project was used to estimate population distribution, and OpenStreetMap was used to determine travel routes. On the basis of geolocations of the facilities, AccessMod 5 was used to estimate the percentage of the population that live within 1 hour, 2 hours, and 4 hours of CCCs under the current (two facilities) and expanded care (seven facilities) scenarios. Variations in access by region, poverty, and level of urbanization were described. RESULTS Currently, 13%, 41%, and 85% of Rwandans can access CCCs within one, two, and 4 hours of travel, respectively. With expansion of CCCs to seven facilities, access increases to 37%, 84%, and 99%, respectively. There is a substantial variation in current geographic access by province, with 1-hour access in Kigali at 98%, whereas access in the Western Province is 0%; care expansion could increase 2-hour access in the Western Province from 1% to 71%. Variation in access is also seen across the level of urbanization, with current 1-hour access in urban versus rural areas of 45% and 8%, respectively. Expanded care results in improvement of 1-hour access to 67% and 33%, respectively. Similar trends were also noted across poverty levels. CONCLUSION Geographical access to CCCs varies substantially by province, level of urbanization, and poverty. These disparities can be alleviated by strategic care expansion to other tertiary care facilities across Rwanda.
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Affiliation(s)
| | - Pranay Nadella
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Hari S. Iyer
- Dana-Farber Cancer Institute, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | | | | | | | - Scott A. Triedman
- Dana-Farber Cancer Institute, Boston, MA
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Timothy R. Rebbeck
- Dana-Farber Cancer Institute, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
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Access to care following injury in Northern Malawi, a comparison of travel time estimates between Geographic Information System and community household reports. Injury 2022; 53:1690-1698. [PMID: 35153068 DOI: 10.1016/j.injury.2022.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 02/02/2023]
Abstract
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.
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Bouanchaud P, Macharia PM, Demise EG, Nakimuli D. Comparing modelled with self-reported travel time and the used versus the nearest facility: modelling geographic accessibility to family planning outlets in Kenya. BMJ Glob Health 2022; 7:e008366. [PMID: 35523451 PMCID: PMC9083396 DOI: 10.1136/bmjgh-2021-008366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/19/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Geographic access to family planning (FP) services has been characterised through a variety of proximity metrics. However, there is little evidence on the validity of women's self-reported compared with modelled travel time to an FP outlet, or between different distance measures. METHODS We used data from four urban sites in Kenya. A longitudinal FP outlet census was directly linked with data from cross-sectional FP user surveys. We combined characteristics of outlet visited to obtain FP, transport mode, self-reported travel time and location of households and outlets with data on road networks, elevation, land use and travel barriers within a cost-distance algorithm to compute modelled travel time, route and Euclidean distance between households and outlets. We compared modelled and self-reported travel times, Euclidean and route distances and the use of visited versus nearest facility. RESULTS 931 contraceptive users were directly linked to their FP source. Self-reported travel times were consistently and significantly higher than modelled times, with greater differences for those using vehicles rather than walking. Modelled and Euclidean distances were similar in the four geographies. 20% of women used their nearest FP outlet while 52% went to their nearest outlet when conditional on it offering their most recently used FP method. CONCLUSION In urban areas with high facility density and good road connectivity, over half of FP users visited their nearest outlet with their chosen method available. In these settings, Euclidean distances were sufficient to characterise geographic proximity; however, reported and modelled travel times differed across all sites.
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Affiliation(s)
- Paul Bouanchaud
- Strategy & Insights, Population Services International, Washington, DC, USA
| | - Peter M Macharia
- Population Health Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Eden G Demise
- SRH, Population Services International, Washington, DC, USA
| | - Doreen Nakimuli
- Strategic Information & Learning, Population Services International, Kampala, Uganda
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18
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Banke-Thomas A, Avoka CKO, Gwacham-Anisiobi U, Omololu O, Balogun M, Wright K, Fasesin TT, Olusi A, Afolabi BB, Ameh C. Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study. BMJ Glob Health 2022; 7:bmjgh-2022-008604. [PMID: 35487675 PMCID: PMC9058694 DOI: 10.1136/bmjgh-2022-008604] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Prompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria. Methods We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death. Findings Of 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4–18.0) and 26 mins (IQR 12–50). For all women, travelling 10–15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10–15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25–35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10–29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas. Conclusion Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- LSE Health, London School of Economics and Political Science, London, UK .,School of Human Sciences, University of Greenwich, Greenwich, London, UK.,Maternal and Reproductive Health Research Collective, Lagos, Nigeria
| | - Cephas Ke-On Avoka
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Greater Accra, Ghana
| | | | - Olufemi Omololu
- Department of Obstetrics and Gynaecology, Lagos Island Maternity Hospital, Lagos, Nigeria
| | - Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Kikelomo Wright
- Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - Tolulope Temitayo Fasesin
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Adedotun Olusi
- Department of Obstetrics and Gynaecology, Federal Medical Centre Ebute-Metta, Ebute-Metta, Lagos, Nigeria
| | - Bosede Bukola Afolabi
- Maternal and Reproductive Health Research Collective, Lagos, Nigeria.,Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Charles Ameh
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Merseyside, UK
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Use of geospatial analysis for priority setting in surgical system investment in Guatemala. LANCET REGIONAL HEALTH. AMERICAS 2021; 7:100145. [PMID: 36777659 PMCID: PMC9904083 DOI: 10.1016/j.lana.2021.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Two-hour and 30 min travel times to a hospital capable of performing emergency general surgery and cesarean section are benchmarks for timely surgical access. This study aimed to estimate the population of Guatemala with timely access to surgical care and identify existing hospitals where the expansion of surgical services would increase access. Methods The World Federation of Societies of Anaesthesiologists (WFSA) Anesthesia Facility Assessment Tool (AFAT) previously identified 37 public Guatemalan hospitals that provide surgical care. Nine additional public non-surgical hospitals were also identified. Geospatial analysis was performed to estimate walking and driving geographic access to all 46 hospitals. We calculated the potential increase in access that would accompany the expansion of surgical services at each of the nine non-surgical hospitals. Findings The percentage of the population with walking access to a surgical hospital within 30 min, 1 h, and 2 h are 5·1%, 12·9%, and 27·3%, respectively. The percentage of people within 30 min, 1 h, and 2 h driving times are 27·3%, 41·1%, and 53·1%, respectively. The median percentage of the population within each of Guatemala's 22 administrative departments with 2 h walking access was 19·0% [IQR 14·1-30·7] and 2 h driving access was 52·4% [IQR 30·5-62·8]. Expansion of surgical care at existing public Guatemalan hospitals in Guatemala would result in a minimal increase in overall geographic access compared to current availability. Interpretation While Guatemala provides universal health coverage, geographic access to surgical care remains inadequate. Geospatial mapping and survey data work synergistically to assess surgical system strength and identify gaps in geographic access to essential surgical care. Funding None.
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20
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Banke-Thomas A, Wong KLM, Collins L, Olaniran A, Balogun M, Wright O, Babajide O, Ajayi B, Afolabi BB, Abayomi A, Benova L. An assessment of geographical access and factors influencing travel time to emergency obstetric care in the urban state of Lagos, Nigeria. Health Policy Plan 2021; 36:1384-1396. [PMID: 34424314 PMCID: PMC8505861 DOI: 10.1093/heapol/czab099] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/28/2021] [Accepted: 08/12/2021] [Indexed: 12/14/2022] Open
Abstract
Previous efforts to estimate the travel time to comprehensive emergency obstetric care (CEmOC) in low- and middle-income countries (LMICs) have either been based on spatial models or self-reported travel time, both with known inaccuracies. The study objectives were to estimate more realistic travel times for pregnant women in emergency situations using Google Maps, determine system-level factors that influence travel time and use these estimates to assess CEmOC geographical accessibility and coverage in Lagos state, Nigeria. Data on demographics, obstetric history and travel to CEmOC facilities of pregnant women with an obstetric emergency, who presented between 1st November 2018 and 31st December 2019 at a public CEmOC facility were collected from hospital records. Estimated travel times were individually extracted from Google Maps for the period of the day of travel. Bivariate and multivariate analyses were used to test associations between travel and health system-related factors with reaching the facility >60 minutes. Mean travel times were compared and geographical coverage mapped to identify ‘hotspots’ of predominantly >60 minutes travel to facilities. For the 4005 pregnant women with traceable journeys, travel time ranges were 2–240 minutes (without referral) and 7–320 minutes (with referral). Total travel time was within the 60 and 120 minute benchmark for 80 and 96% of women, respectively. The period of the day of travel and having been referred were significantly associated with travelling >60 minutes. Many pregnant women living in the central cities and remote towns typically travelled to CEmOC facilities around them. We identified four hotspots from which pregnant women travelled >60 minutes to facilities. Mean travel time and distance to reach tertiary referral hospitals were significantly higher than the secondary facilities. Our findings suggest that actions taken to address gaps need to be contextualized. Our approach provides a useful guide for stakeholders seeking to comprehensively explore geographical inequities in CEmOC access within urban/peri-urban LMIC settings.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK.,Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Oba Akinjobi Street, Ikeja, P.M.B. 21266, Lagos, Nigeria
| | - Kerry L M Wong
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Lindsey Collins
- School of Geographical Sciences and Urban Planning, Arizona State University, South Myrtle Avenue, Tempe, Arizona 85281, USA
| | - Abimbola Olaniran
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi Araba, PMB 12003, Lagos, Nigeria
| | - Ololade Wright
- Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Oba Akinjobi Street, Ikeja, P.M.B. 21266, Lagos, Nigeria.,Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Oba Akinjobi Street, Ikeja, P.M.B. 21266, Lagos, Nigeria
| | - Opeyemi Babajide
- Department of Epidemiology and Medical Statistics, University of Ibadan, Oduduwa Road, 200132, Ibadan, Nigeria
| | - Babatunde Ajayi
- Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Oba Akinjobi Street, Ikeja, P.M.B. 21266, Lagos, Nigeria.,Office of the Commissioner, Lagos State Ministry of Health, Secretariat, Alausa, Lagos, Nigeria
| | - Bosede Bukola Afolabi
- Department of Obstetrics and Gynaecology, College of Medicine of the University of Lagos, Idi Araba, P.M.B 12003, Lagos, Nigeria
| | - Akin Abayomi
- Office of the Commissioner, Lagos State Ministry of Health, Secretariat, Alausa, Lagos, Nigeria
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Kronenburgstraat 43, 2000 Antwerpen, Belgium
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21
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Banke-Thomas A, Avoka CKO, Gwacham-Anisiobi U, Benova L. Influence of travel time and distance to the hospital of care on stillbirths: a retrospective facility-based cross-sectional study in Lagos, Nigeria. BMJ Glob Health 2021; 6:e007052. [PMID: 34615663 PMCID: PMC8496383 DOI: 10.1136/bmjgh-2021-007052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Access to emergency obstetric care can lead to a 45%-75% reduction in stillbirths. However, before a pregnant woman can access this care, she needs to travel to a health facility. Our objective in this study was to assess the influence of distance and travel time to the actual hospital of care on stillbirth. METHODS We conducted a retrospective cross-sectional study of pregnant women who presented with obstetric emergencies over a year across all 24 public hospitals in Lagos, Nigeria. Reviewing clinical records, we extracted sociodemographic, travel and obstetric data. Extracted travel data were exported to Google Maps, where typical distance and travel time for period-of-day they travelled were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on stillbirth. RESULTS Of 3278 births, there were 408 stillbirths (12.5%). Women with livebirths travelled a median distance of 7.3 km (IQR 3.3-18.0) and over a median time of 24 min (IQR 12-51). Those with stillbirths travelled a median distance of 8.5 km (IQR 4.4-19.7) and over a median time of 30 min (IQR 16-60). Following adjustments, though no significant association with distance was found, odds of stillbirth were significantly higher for travel of 10-29 min (OR 2.25, 95% CI 1.40 to 3.63), 30-59 min (OR 2.30, 95% CI 1.22 to 4.34) and 60-119 min (OR 2.35, 95% CI 1.05 to 5.25). The adjusted OR of stillbirth was significantly lower following booking (OR 0.37, 95% CI 0.28 to 0.49), obstetric complications with mother (obstructed labour (OR 0.11, 95% CI 0.07 to 0.17) and haemorrhage (OR 0.30, 95%CI 0.20 to 0.46)). Odds were significantly higher with multiple gestations (OR 2.40, 95% CI 1.57 to 3.69) and referral (OR 1.55, 95% CI 1.13 to 2.12). CONCLUSION Travel time to a hospital was strongly associated with stillbirth. In addition to birth preparedness, efforts to get quality care quicker to women or women quicker to quality care will be critical for efforts to reduce stillbirths in a principally urban low-income and middle-income setting.
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Affiliation(s)
| | - Cephas Ke-On Avoka
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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22
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Iyer HS, Wolf NG, Flanigan JS, Castro MC, Schroeder LF, Fleming K, Vuhahula E, Massambu C. Evaluating urban-rural access to pathology and laboratory medicine services in Tanzania. Health Policy Plan 2021; 36:1116-1128. [PMID: 34212191 PMCID: PMC8359747 DOI: 10.1093/heapol/czab078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/12/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
Placement of pathology and laboratory medicine (PALM) services requires balancing efficiency (maximizing test volume) with equitable urban-rural access. We compared the association between population density (proxy for efficiency) and travel time to the closest facility (proxy for equitable access) across levels of Tanzania's public sector health system. We linked geospatial data for Tanzania from multiple sources. Data on facility locations and other geographic measures were collected from government and non-governmental databases. We classified facilities assuming increasing PALM availability by tier: (1) dispensaries, (2) health centres, (3) district hospitals and (4) regional/referral hospitals. We used the AccessMod 5 algorithm to estimate travel time to the closest facility for each tier across Tanzania with 500-m resolution. District-level average population density and travel time to the closest facility were calculated and presented using medians and interquartile ranges. Spatial correlations between these variables were estimated using the global Moran's I and bivariate Local Indicator of Spatial Autocorrelation, specifying a queen's neighbourhood matrix. Spatial analysis was restricted to 171 contiguous districts. The study included 5406 dispensaries, 675 health centres, 186 district hospitals and 37 regional/referral hospitals. District-level travel times were shortest for Tier 1 (median: [IQR]: 45.4 min [30.0-74.7]) and longest for Tier 4 facilities (160.2 min [107.3-260.0]). There was a weak spatial autocorrelation across tiers (Tier 1: -0.289, Tier 2: -0.292, Tier 3: -0.271 and Tier 4: -0.258) and few districts were classified as significant spatial outliers. Across tiers, geographic patterns of populated districts surrounded by neighbours with short travel time and sparsely populated districts surrounded by neighbours with long travel time were observed. Similar spatial correlation measures across health system levels suggest that Tanzania's health system reflects equitable urban-rural access to different PALM services. Longer travel times to hospital-based care could be ameliorated by shifting specialized diagnostics to more accessible lower tiers.
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Affiliation(s)
- Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
| | - Nicholas G Wolf
- Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, 651 Huntington Ave, Boston, MA 02115, USA
| | - John S Flanigan
- Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, 651 Huntington Ave, Boston, MA 02115, USA
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Lee F Schroeder
- Department of Pathology, University of Michigan, 1301 Catherine St, Ann Arbor, MI 48109, USA
| | - Kenneth Fleming
- Green Templeton College, Oxford University, 43 Woodstock Rd, Oxford OX2 6HG, UK
| | - Edda Vuhahula
- Department of Pathology, Muhimbili University of Health and Allied Sciences, United Nations Rd, Dar es Salaam, TZ
| | - Charles Massambu
- Department of Biomedical Sciences, College of Health Sciences, University of Dodoma, PO Box 259 Dodoma, TZ
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23
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Iyer HS, Flanigan J, Wolf NG, Schroeder LF, Horton S, Castro MC, Rebbeck TR. Geospatial evaluation of trade-offs between equity in physical access to healthcare and health systems efficiency. BMJ Glob Health 2021; 5:bmjgh-2020-003493. [PMID: 33087394 PMCID: PMC7580044 DOI: 10.1136/bmjgh-2020-003493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023] Open
Abstract
Introduction Decisions regarding the geographical placement of healthcare services require consideration of trade-offs between equity and efficiency, but few empirical assessments are available. We applied a novel geospatial framework to study these trade-offs in four African countries. Methods Geolocation data on population density (a surrogate for efficiency), health centres and cancer referral centres in Kenya, Malawi, Tanzania and Rwanda were obtained from online databases. Travel time to the closest facility (a surrogate for equity) was estimated with 1 km resolution using the Access Mod 5 least cost distance algorithm. We studied associations between district-level average population density and travel time to closest facility for each country using Pearson’s correlation, and spatial autocorrelation using the Global Moran’s I statistic. Geographical clusters of districts with inefficient resource allocation were identified using the bivariate local indicator of spatial autocorrelation. Results Population density was inversely associated with travel time for all countries and levels of the health system (Pearson’s correlation range, health centres: −0.89 to −0.71; cancer referral centres: −0.92 to −0.43), favouring efficiency. For health centres, negative spatial autocorrelation (geographical clustering of dissimilar values of population density and travel time) was weaker in Rwanda (−0.310) and Tanzania (−0.292), countries with explicit policies supporting equitable access to rural healthcare, relative to Kenya (−0.579) and Malawi (−0.543). Stronger spatial autocorrelation was observed for cancer referral centres (Rwanda: −0.341; Tanzania: −0.259; Kenya: −0.595; Malawi: −0.666). Significant geographical clusters of sparsely populated districts with long travel times to care were identified across countries. Conclusion Negative spatial correlations suggested that the geographical distribution of health services favoured efficiency over equity, but spatial autocorrelation measures revealed more equitable geographical distribution of facilities in certain countries. These findings suggest that even when prioritising efficiency, thoughtful decisions regarding geographical allocation could increase equitable physical access to services.
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Affiliation(s)
- Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA .,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - John Flanigan
- Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nicholas G Wolf
- Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Susan Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Marcia C Castro
- Department of Global Health and Population, Harvard University T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Timothy R Rebbeck
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, United States.,Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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24
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Banke-Thomas A, Wong KLM, Ayomoh FI, Giwa-Ayedun RO, Benova L. "In cities, it's not far, but it takes long": comparing estimated and replicated travel times to reach life-saving obstetric care in Lagos, Nigeria. BMJ Glob Health 2021; 6:bmjgh-2020-004318. [PMID: 33495286 PMCID: PMC7839900 DOI: 10.1136/bmjgh-2020-004318] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/19/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Travel time to comprehensive emergency obstetric care (CEmOC) facilities in low-resource settings is commonly estimated using modelling approaches. Our objective was to derive and compare estimates of travel time to reach CEmOC in an African megacity using models and web-based platforms against actual replication of travel. METHODS We extracted data from patient files of all 732 pregnant women who presented in emergency in the four publicly owned tertiary CEmOC facilities in Lagos, Nigeria, between August 2018 and August 2019. For a systematically selected subsample of 385, we estimated travel time from their homes to the facility using the cost-friction surface approach, Open Source Routing Machine (OSRM) and Google Maps, and compared them to travel time by two independent drivers replicating women's journeys. We estimated the percentage of women who reached the facilities within 60 and 120 min. RESULTS The median travel time for 385 women from the cost-friction surface approach, OSRM and Google Maps was 5, 11 and 40 min, respectively. The median actual drive time was 50-52 min. The mean errors were >45 min for the cost-friction surface approach and OSRM, and 14 min for Google Maps. The smallest differences between replicated and estimated travel times were seen for night-time journeys at weekends; largest errors were found for night-time journeys at weekdays and journeys above 120 min. Modelled estimates indicated that all participants were within 60 min of the destination CEmOC facility, yet journey replication showed that only 57% were, and 92% were within 120 min. CONCLUSIONS Existing modelling methods underestimate actual travel time in low-resource megacities. Significant gaps in geographical access to life-saving health services like CEmOC must be urgently addressed, including in urban areas. Leveraging tools that generate 'closer-to-reality' estimates will be vital for service planning if universal health coverage targets are to be realised by 2030.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- LSE Health, London School of Economics and Political Science, London, UK .,Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Lagos, Nigeria
| | - Kerry L M Wong
- Infectious Disease and Epidemiology, London School of Hygiene & Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| | - Francis Ifeanyi Ayomoh
- Department of Health Planning, Research and Statistics, Federal Ministry of Health, Abuja, Nigeria
| | | | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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25
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Whitaker J, O'Donohoe N, Denning M, Poenaru D, Guadagno E, Leather AJM, Davies JI. 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. BMJ Glob Health 2021; 6:e004324. [PMID: 33975885 PMCID: PMC8118008 DOI: 10.1136/bmjgh-2020-004324] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- John Whitaker
- King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - Max Denning
- Department of Surgery and Cancer, Imperial College London, London, UK
- Stanford Graduate School of Business, Stanford University, Stanford, California, USA
| | - Dan Poenaru
- Harvey E Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Elena Guadagno
- Harvey E Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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26
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Carrillo-Villaseñor F, Fowler Z, Moeller E, Roa L, Macias V, Koch R, Mohar S, Caddell L, Cervantes S, Mathews I, Riviello R, Cervantes-Trejo A, Meara JG, Uribe-Leitz T. Access to Essential Surgical Care in Chiapas, Mexico: A System-Wide Geospatial Analysis. World J Surg 2021; 45:1663-1671. [PMID: 33616710 DOI: 10.1007/s00268-021-05975-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Long travel times to reach essential surgical care in Chiapas, Mexico's poorest state, can delay lifesaving procedures and contribute to adverse outcomes. Geographical access to surgical facilities is 1 of the 6 indicators of the Lancet Commission on Global Surgery and has been measured extensively worldwide. Our objective is to determine the population with 2-h geographical access to facilities capable of performing the Bellwether procedures (laparotomy, cesarean delivery, and open fracture repair). This is the first study in Mexico to assess access to surgical facilities, including both the fragmented public sector and the private sector. METHODS In this cross-sectional study, conducted from June 2019 to January 2020, Bellwether capable surgical facilities from all health systems in Chiapas were geocoded and assessed through on-site data collection, Ministry of Health databases, and verified via telephone. Geospatial analyses were performed on Redivis. RESULTS We identified 59 Bellwether capable hospitals, with 17.5% (n = 954,460) of the state residing more than 2 h from surgical care in public and private health systems. Of those, 22 facilities had confirmed 24/7 Bellwether capability, and 23% (n = 1,178,383) of the affiliated population resided more than 2 h from these hospitals. CONCLUSIONS Our study shows that the Ministry of Health and employment-based health coverage could provide timely access to essential surgical care for the majority of the population. However, the fragmentation of the healthcare system leaves a gap that contributes to delays in care and unmet emergency surgical needs.
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Affiliation(s)
- Fernando Carrillo-Villaseñor
- Compañeros en Salud, Jaltenango, CHIS, México. .,Ciencias de la Salud y Escuela de Medicina, Tecnológico de Monterrey, 2514 Av. Gral Ramón Corona, 45201, Guadalajara, JAL, México.
| | - Zachary Fowler
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Ellie Moeller
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Institute for Advanced Study of the Americas, University of Miami, Miami, FL, USA
| | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | | | - Rachel Koch
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sebastián Mohar
- Compañeros en Salud, Jaltenango, CHIS, México.,Hospital Básico Comunitario Ángel Albino Corzo, Secretaría de Salud, Jaltenango, CHIS, México
| | - Luke Caddell
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Sabrina Cervantes
- Hospital Básico Comunitario Ángel Albino Corzo, Secretaría de Salud, Jaltenango, CHIS, México
| | | | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Arturo Cervantes-Trejo
- Anahuac Institute of Public Health and Carlos Peralta Chair of Public Health, Faculty of Health Sciences, Universidad Anáhuac, Huixquilucan, MEX, México
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Tarsicio Uribe-Leitz
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA.,Department of Sport and Health Sciences, Technical University Munich,Epidemiology, Munchen, Germany
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van Duinen AJ, Adde HA, Fredin O, Holmer H, Hagander L, Koroma AP, Koroma MM, Leather AJ, Wibe A, Bolkan HA. Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone. BMJ Glob Health 2020; 5:e003943. [PMID: 33355267 PMCID: PMC7754652 DOI: 10.1136/bmjgh-2020-003943] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. METHODS Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. RESULTS The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). CONCLUSION The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off.
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Affiliation(s)
- Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håvard A Adde
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ola Fredin
- Geological Survey of Norway, Trondheim, Norway
- Department of Geography, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hampus Holmer
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Hagander
- Centre for Surgery and Public Health, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Alimamy P Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Michael M Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Andrew Jm Leather
- King's Centre for Global Health & Health Partnerships, King's College London, London, UK
| | - Arne Wibe
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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