1
|
Whitaker J, Njawala T, Nyirenda V, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard R, Leather AJM, Davies J. Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff survey. PLoS One 2024; 19:e0308525. [PMID: 39264901 PMCID: PMC11392338 DOI: 10.1371/journal.pone.0308525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 07/25/2024] [Indexed: 09/14/2024] Open
Abstract
INTRODUCTION The burden of injuries globally and in Malawi is substantial. Optimising both access to, and quality of, care in health systems requires attention. We aimed to establish how health facility staff in Karonga, Malawi, perceive barriers to seeking (delay 1), reaching (delay 2) and receiving (delay 3) injury care. METHOD We conducted a cross-sectional survey of health facility staff who treat patients with injuries in all health facilities serving the Karonga Demographic Surveillance Site population. The primary outcome was participant perceptions of the importance of delays 1 to 3 following injury. Secondary outcomes were the barriers within each of these delays considered most important and which were considered the most important across all delays stages. RESULTS 228 staff completed the survey: 36.8% (84/228) were female and 61.4% (140/228) reported being involved in caring for an injured person at least weekly. Delay 3 was most frequently considered the most important delay 35.1% (80/228), with 19.3% (44/228) and 16.6% (38/228) reporting delays 1 and 2 as the most important respectively; 28.9% (66/228) of respondents either did not know or answer. For delay 1 the barrier, "the perceived financial costs associated with seeking care are too great", was considered most important. For delay 2, the barrier "lack of timely affordable emergency transport (formal or informal)" was considered most important. For delay 3, the barrier, "lack of reliably available necessary physical resources (infrastructure, equipment and consumable material)" was considered most important. When considering the most important overall barrier across all delays, the delay 3 barrier, "lack of reliably available necessary physical resources" received the most nominations (41.7% [95/228]). CONCLUSIONS Given the awareness of health facility staff of the issues facing their patients, these findings should assist in informing health system planning.
Collapse
Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Taniel Njawala
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Vitumbeku Nyirenda
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - 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
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - 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
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Andrew J M Leather
- School of Life Course and Population Sciences, 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
| |
Collapse
|
2
|
Usmani BA, Lakhdir MPA, Sameen S, Batool S, Odland ML, Goodman-Palmer D, Agyapong-Badu S, Hirschhorn LR, Greig C, Davies J. Exploring the priorities of ageing populations in Pakistan, comparing views of older people in Karachi City and Thatta. PLoS One 2024; 19:e0304474. [PMID: 38968322 PMCID: PMC11226073 DOI: 10.1371/journal.pone.0304474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 05/13/2024] [Indexed: 07/07/2024] Open
Abstract
As a lower middle-income country, Pakistan faces multiple issues that influence the course of healthy ageing. Although there is some understanding of these issues and the objective health outcomes of people in Pakistan, there is less knowledge on the perceptions, experiences, and priorities of the ageing population and their caretakers (hereafter, "stakeholders"). The aim of the study was to identify the needs and priorities of older adults and stakeholders across both urban and rural locations. We sought to explore the views of two groups of people, older adults and stakeholders on topics including the definition of ageing as well as areas of importance, services available, and barriers to older people living well. Two-day workshops were conducted in one rural city, Thatta and one urban city, Karachi. The workshops were designed using the Nominal Group Technique, which included plenary and roundtable discussions. The responses were ranked through rounds of voting and a consensus priority list was obtained for each topic and group. Responses were categorized using the socio-ecological framework. Responses were compared between stakeholders and older people and between different geographical areas. 24 urban and 26 rural individuals aged over 60 years and 24 urban and 26 rural stakeholders attended the workshops. There were few areas of agreement with respect to both geographical region and participant group. Comparing older adults' definition of ageing, there was no overlap between the top five ranked responses across urban and rural locations. With respect to areas of importance, there was agreement on free health care as well as financial support. In terms of barriers to healthy ageing, only nation-wide inflation was ranked highly by both groups. In addition, there were relatively few areas of congruence between stakeholder and older adult responses, irrespective of location, although engagement with family, adequate nutrition and monetary benefits were responses ranked by both groups as important for healthy ageing. Both groups ranked issues with the pension system and financial difficulties as barriers. When categorized using the socio-ecological model, across all questions, societal factors were prioritized most frequently (32 responses), followed by individual (27), relationship (15), and environment (14). Overcoming barriers to facilitate healthy ageing will require a multi-faceted approach and must incorporate the priorities of older individuals. Our results may serve as a guide for researchers and policymakers for future engagement and to plan interventions for improving the health of the ageing population in Pakistan.
Collapse
Affiliation(s)
- Bilal Ahmed Usmani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
- Department of Biomedical Engineering, NED University of Engineering and Technology, Karachi, Pakistan
| | - Maryam Pyar Ali Lakhdir
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sonia Sameen
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Saila Batool
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
- BSc Medical Bioscience Monash University Malaysia, School of Science, Subang Jaya, Malaysia
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Department of Obstetrics and Gynecology, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dina Goodman-Palmer
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Sandra Agyapong-Badu
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lisa R. Hirschhorn
- Department of Medical Social Sciences and Havey Institute of Global Health, Feinberg School of Medicine, Northwestern University, Evanston, IL, United States of America
| | - Carolyn Greig
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
3
|
Kennedy C, Ignatowicz A, Odland ML, Abdul-Latif AM, Belli A, Howard A, Whitaker J, Chu KM, Ferreira K, Owolabi EO, Nyamathe S, Tabiri S, Ofori B, Pognaa Kunfah SM, Yakubu M, Bekele A, Alyande B, Nzasabimana P, Byiringiro JC, Davies J. Commonalities and differences in injured patient experiences of accessing and receiving quality injury care: a qualitative study in three sub-Saharan African countries. BMJ Open 2024; 14:e082098. [PMID: 38955369 PMCID: PMC11218010 DOI: 10.1136/bmjopen-2023-082098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVES To understand commonalities and differences in injured patient experiences of accessing and receiving quality injury care across three lower-income and middle-income countries. DESIGN A qualitative interview study. The interviews were audiorecorded, transcribed and thematically analysed. SETTING Urban and rural settings in Ghana, South Africa and Rwanda. PARTICIPANTS 59 patients with musculoskeletal injuries. RESULTS We found five common barriers and six common facilitators to injured patient experiences of accessing and receiving high-quality injury care. The barriers encompassed issues such as service and treatment availability, transportation challenges, apathetic care, individual financial scarcity and inadequate health insurance coverage, alongside low health literacy and information provision. Facilitators included effective information giving and informed consent practices, access to health insurance, improved health literacy, empathetic and responsive care, comprehensive multidisciplinary management and discharge planning, as well as both informal and formal transportation options including ambulance services. These barriers and facilitators were prevalent and shared across at least two countries but demonstrated intercountry and intracountry (between urbanity and rurality) variation in thematic frequency. CONCLUSION There are universal factors influencing patient experiences of accessing and receiving care, independent of the context or healthcare system. It is important to recognise and understand these barriers and facilitators to inform policy decisions and develop transferable interventions aimed at enhancing the quality of injury care in sub-Saharan African nations.
Collapse
Affiliation(s)
- Ciaran Kennedy
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, St. Olavs University Hospital, Trondheim, Norway
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Abdul-Malik Abdul-Latif
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Volta Regional Health Directorate, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Antonio Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Anthony Howard
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Centre, University of Oxford, Headington, UK
| | - John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Kathryn M Chu
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
- Department of Surgery, University of Botswana, Gaborone, Botswana
| | - Karen Ferreira
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Eyitayo O Owolabi
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Samukelisiwe Nyamathe
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Stephen Tabiri
- Ghana HUB of NIHR Global Surgery, Tamale, Ghana
- Department of Public Health, Tamale Teaching Hospital, Tamale, Ghana
- Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | | | | | - Mustapha Yakubu
- Department of Public Health, Tamale Teaching Hospital, Tamale, Ghana
- School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Barnabas Alyande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jean-Claude Byiringiro
- University of Rwanda, Kigali, Rwanda
- Department of Surgery, University Teaching Hospital, Kigali, Rwanda
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
- 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
| |
Collapse
|
4
|
Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise. BMJ Open 2024; 14:e085064. [PMID: 38925682 PMCID: PMC11202735 DOI: 10.1136/bmjopen-2024-085064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement. DESIGN Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations. SETTING The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients. PARTICIPANTS 24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites. RESULTS Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making. DISCUSSION We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.
Collapse
|
5
|
Casadei Donatelli D, Goodman-Palmer D, Odland ML, Agyapong-Badu S, da Cruz-Alves N, Rosenburg M, Hirschhorn LR, Greig C, Davies J, Barbosa do Nascimento V, Ferriolli E. Identification of the needs and priorities of older people and stakeholders in rural and urban areas of Santo Andre, Brazil. PLoS One 2024; 19:e0297489. [PMID: 38722852 PMCID: PMC11081258 DOI: 10.1371/journal.pone.0297489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 01/05/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND There are few data reporting the needs and priorities of older adults in Brazil. This hampers the development and/or implementation of policies aimed at older adults to help them age well. The aim of this study was to understand areas of importance, priorities, enablers and obstacles to healthy ageing as identified by older adults and key stakeholders in both urban and rural environments. METHODS Two locations were selected, one urban and one rural in the municipality of Santo André, in the metropolitan region of São Paulo (SP). Workshops for older adults (>60 y) and stakeholders were conducted separately in each location. The workshops incorporated an iterative process of discussion, prioritisation and ranking of responses, in roundtable groups and in plenary. Areas of commonality and differences between older adult and stakeholder responses were identified by comparing responses between groups as well as mapping obstacles and enablers to healthy ageing identified by older adults, to the priorities identified by stakeholder groups. The socio-ecologic model was used to categorise responses. RESULTS There were few shared responses between stakeholders and older adults and little overlap between the top ranked responses of urban and rural groups. With respect to areas of importance, both stakeholder groups ranked policies for older people within their top five reponses. Both older adult groups ranked keeping physically and mentally active, and nurturing spirituality. There was a marked lack of congruence between older adults' obstacles and enablers to healthy ageing and stakeholder priorities, in both urban and rural settings. Most responses were located within the Society domain of the socio-ecologic model, although older adults also responded within the Individual/ Relationships domains, particularly in ranking areas of most importance for healthy ageing. CONCLUSIONS Our results highlight substantial differences between older adults and stakeholders with respect to areas of importance, priorities, enablers and obstacles to healthy ageing, and point to the need for more engagement between those in advocacy and policymaking roles and the older people whose needs they serve.
Collapse
Affiliation(s)
| | - Dina Goodman-Palmer
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Department of Obstetrics and Gynecology, St Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sandra Agyapong-Badu
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Natalia da Cruz-Alves
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Meire Rosenburg
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Lisa R. Hirschhorn
- Department of Medical Social Sciences and Havey Institute of Global Health, Feinberg School of Medicine, Northwestern University, Evanston, IL, United States of America
| | - Carolyn Greig
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | | | - Eduardo Ferriolli
- Faculdade de Medicina, Laboratorio de Investigaçao Medica em Envelhecimento (LIM-66), Serviço de Geriatria, Hospital das Clinicas, Disciplina de Geriatria, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
6
|
Whitaker J, Edem I, Amoah AS, Dube A, D'Ambruoso L, Rickard RF, Leather AJM, Davies J. Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data. BMJ Open 2024; 14:e081652. [PMID: 38684258 PMCID: PMC11086451 DOI: 10.1136/bmjopen-2023-081652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care. DESIGN Retrospective analysis of existing VA data routinely collected by a demographic surveillance site. SETTING Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi. PARTICIPANTS Fatally injured members of the HDSS. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system. RESULTS Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49). CONCLUSIONS VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.
Collapse
Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Idara Edem
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, USA
- Michigan State University, East Lansing, Michigan, USA
| | - Abena S Amoah
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- 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
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health, National Health Service (NHS) Grampian, Grampian, Scotland
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andy J M Leather
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- 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
| |
Collapse
|
7
|
Davies J, Chu K, Tabiri S, Byiringiro JC, Bekele A, Razzak J, D’Ambruoso L, Ignatowicz A, Bojke L, Nkonki L, Laurenzi C, Sitch A, Bagahirwa I, Belli A, Sam NB, Amberbir A, Whitaker J, Ndangurura D, Ghalichi L, MacQuene T, Tshabalala N, Fikadu Berhe D, Nepomuscene NJ, Agbeko AE, Sarfo-Antwi F, Babar Chand Z, Wajidali Z, Sahibjan F, Atiq H, Mali Y, Tshabalala Z, Khalfe F, Nodo O, Umwali G, Twizeyimana E, Mugisha N, Munyura NO, Nakure S, Ishimwe SMC, Nzasabimana P, Dramani A, Acquaye J, Tanweer A. Equitable access to quality injury care; Equi-Injury project protocol for prioritizing interventions in four low- or middle-income countries: a mixed method study. BMC Health Serv Res 2024; 24:429. [PMID: 38576004 PMCID: PMC10996087 DOI: 10.1186/s12913-024-10668-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/31/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Equitable access to quality care after injury is an essential step for improved health outcomes in low- and middle-income countries (LMICs). We introduce the Equi-Injury project, in which we will use integrated frameworks to understand how to improve equitable access to quality care after injury in four LMICs: Ghana, Pakistan, Rwanda and South Africa. METHODS This project has 5 work packages (WPs) as well as essential cross-cutting pillars of community engagement, capacity building and cross-country learning. In WP1, we will identify needs, barriers, and facilitators to impactful stakeholder engagement in developing and prioritising policy solutions. In WP2, we will collect data on patient care and outcomes after injuries. In WP3, we will develop an injury pathway model to understand which elements in the pathway of injury response, care and treatment have the biggest impact on health and economic outcomes. In WP4, we will work with stakeholders to gain consensus on solutions to address identified issues; these solutions will be implemented and tested in future research. In WP5, in order to ascertain where learning is transferable across contexts, we will identify which outcomes are shared across countries. The study has received approval from ethical review boards (ERBs) of all partner countries in South Africa, Rwanda, Ghana, Pakistan and the University of Birmingham. DISCUSSION This health system evaluation project aims to provide a deeper understanding of injury care and develop evidence-based interventions within and across partner countries in four diverse LMICs. Strong partnership with multiple stakeholders will facilitate utilisation of the results for the co-development of sustainable interventions.
Collapse
|
8
|
Mazzucchi A. Cognitive evaluation and rehabilitation in high- and low-income countries. J Neuropsychol 2024; 18:1-14. [PMID: 37424164 DOI: 10.1111/jnp.12338] [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: 12/22/2022] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/11/2023]
Abstract
Starting from her own personal experience, in the First Part of the article, the author reconstructs how the specialized sectors of cognitive evaluation and rehabilitation evolved in Western countries (Europe, the United States, Canada, and Australia, in particular) during the second half of the last century and the first decades of this century. In the Second Part, she describes her personal experience in setting up a rehabilitation centre dedicated to traumatic brain-injured subjects and her commitment to international cooperation (Bolivia, Rwanda, Myanmar, Tanzania) in the field of cognitive evaluation and rehabilitation in favour of people with congenital and acquired cerebral pathology, especially in the paediatric age, since there is an almost total lack of diagnostic, but above all, rehabilitative procedures for cognitive functions in low-middle income countries. In the Third Part of the article, the author carries out an extensive review of the international literature on the differences in access to cognitive diagnostic evaluation and cognitive rehabilitation in middle- and low-income countries - but not only - underlining the urgent need to launch a major international collaborative effort to reduce and eliminate these discrepancies.
Collapse
Affiliation(s)
- Anna Mazzucchi
- Former Teacher of Neuropsychology and Neurological Rehabilitation, University of Parma, Parma PR, Italy
| |
Collapse
|
9
|
Whitaker J, Amoah AS, Dube A, Rickard R, Leather AJM, Davies J. Access to quality care after injury in Northern Malawi: results of a household survey. BMC Health Serv Res 2024; 24:131. [PMID: 38268016 PMCID: PMC10809521 DOI: 10.1186/s12913-023-10521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury. METHODS We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked. RESULTS Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142). CONCLUSION Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.
Collapse
Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
- 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, UK.
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (Formerly Karonga Prevention Study), Chilumba, Malawi
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (Formerly Karonga Prevention Study), Chilumba, Malawi
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M 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, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- 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
| |
Collapse
|
10
|
Ghalichi L, Goodman-Palmer D, Whitaker J, Abio A, Wilson ML, Wallis L, Norov B, Aryal KK, Malta DC, Bärnighausen T, Geldsetzer P, Flood D, Vollmer S, Theilmann M, Davies J. Individual characteristics associated with road traffic collisions and healthcare seeking in low- and middle-income countries and territories. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002768. [PMID: 38241424 PMCID: PMC10798533 DOI: 10.1371/journal.pgph.0002768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/05/2023] [Indexed: 01/21/2024]
Abstract
Incidence of road traffic collisions (RTCs), types of users involved, and healthcare requirement afterwards are essential information for efficient policy making. We analysed individual-level data from nationally representative surveys conducted in low- or middle-income countries (LMICs) between 2008-2019. We describe the weighted incidence of non-fatal RTC in the past 12 months, type of road user involved, and incidence of traffic injuries requiring medical attention. Multivariable logistic regressions were done to evaluate associated sociodemographic and economic characteristics, and alcohol use. Data were included from 90,790 individuals from 15 countries or territories. The non-fatal RTC incidence in participants aged 24-65 years was 5.2% (95% CI: 4.6-5.9), with significant differences dependent on country income status. Drivers, passengers, pedestrians and cyclists composed 37.2%, 40.3%, 11.3% and 11.2% of RTCs, respectively. The distribution of road user type varied with country income status, with divers increasing and cyclists decreasing with increasing country income status. Type of road users involved in RTCs also varied by the age and sex of the person involved, with a greater proportion of males than females involved as drivers, and a reverse pattern for pedestrians. In multivariable analysis, RTC incidence was associated with younger age, male sex, being single, and having achieved higher levels of education; there was no association with alcohol use. In a sensitivity analysis including respondents aged 18-64 years, results were similar, however, there was an association of RTC incidence with alcohol use. The incidence of injuries requiring medical attention was 1.8% (1.6-2.1). In multivariable analyses, requiring medical attention was associated with younger age, male sex, and higher wealth quintile. We found remarkable heterogeneity in RTC incidence, the type of road users involved, and the requirement for medical attention after injuries depending on country income status and socio-demographic characteristics. Targeted data-informed approaches are needed to prevent and manage RTCs.
Collapse
Affiliation(s)
- Leila Ghalichi
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Dina Goodman-Palmer
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - 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
| | - Anne Abio
- Injury Epidemiology and Prevention Research Group, Turku Brain Injury Centre, Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland
- INVEST Research Flagship Center, University of Turku, Turku, Finland
| | - Michael Lowery Wilson
- Injury Epidemiology and Prevention Research Group, Turku Brain Injury Centre, Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Lee Wallis
- Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Bolormaa Norov
- Department of Nutrition and Food Safety, National Center for Public Health, Ulaanbaatar, Mongolia
| | - Krishna Kumar Aryal
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Deborah Carvalho Malta
- Universidade Federal de Minas Gerais, Departamento de Enfermagem Materno Infantil e Saúde Pública, Belo Horizonte, MG, Brasil
| | - Till Bärnighausen
- Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
- Chan Zuckerberg Biohub–San Francisco, San Francisco, California, United States of America
| | - David Flood
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Michaela Theilmann
- Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Louw J, McCaul M, English R, Nyasulu PS, Davies J, Fourie C, Jassat J, Chu KM. Factors Contributing to Delays to Accessing Appendectomy in Low- and Middle-Income Countries: A Scoping Review. World J Surg 2023; 47:3060-3069. [PMID: 37747549 PMCID: PMC10694117 DOI: 10.1007/s00268-023-07183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Appendicitis is one of the most common emergency surgical conditions worldwide. Delays in accessing appendectomy can lead to complications. Evidence on these delays in low- and middle-income countries (LMICs) is lacking. The aim of this review was to identify and synthesise the available evidence on delays to accessing appendectomy in LMICs. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews framework. The delays and their interconnectivity in LMICs were synthesised and interpreted using the Three Delays framework. We reviewed Africa Wide EBSCOhost, PubMed-Medline, Scopus, Web of Science, African Journals Online (AJOL), and Bioline databases. RESULTS Our search identified 21 893 studies, of which 78 were included in the final analysis. All of the studies were quantitative. Fifty per cent of the studies included all three types of delays. Delays in seeking care were influenced by a lack of awareness of appendicitis symptoms, and the use of self and alternative medication, which could be linked to delays in receiving care, and the barrier refusal of medical treatment due to fear. Financial concerns were a barrier observed throughout the care pathway. CONCLUSION This review highlighted the need for additional studies on delays to accessing appendectomy in additional LMICs. Our review demonstrates that in LMICs, persons seeking appendectomy present late to health-care facilities due to several patient-related factors. After reaching a health-care facility, accessing appendectomy can further be delayed owing to a lack of adequate hospital resources.
Collapse
Affiliation(s)
- Johnelize Louw
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - M McCaul
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - P S Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Davies
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - C Fourie
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J Jassat
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - K M Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Surgery, University of Botswana, Plot 4775 Notwane Rd, Gaborone, Botswana
| |
Collapse
|
13
|
Ali AE, Sharma S, Elebute OA, Ademuyiwa A, Mashavave NZ, Chitnis M, Abib S, Wahid FN. Trauma and sexual abuse in children-Epidemiology, challenges, management strategies and prevention in lower- and middle-income countries. Semin Pediatr Surg 2023; 32:151356. [PMID: 38041908 DOI: 10.1016/j.sempedsurg.2023.151356] [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] [Indexed: 12/04/2023]
Abstract
Trauma is rising as a cause of morbidity and mortality in lower- and middle-income countries (LMIC). This article describes the Epidemiology, Challenges, Management strategies and prevention of pediatric trauma in lower- and middle-income countries. The top five etiologies for non-intentional injuries leading to death are falls, road traffic injuries, burns, drowning and poisoning. The mortality rate in LMICs is twice that of High-Income Countries (HICs) irrespective of injury severity adjustment. The reasons for inadequate care include lack of facilities, transportation problems, lack of prehospital care, lack of resources and trained manpower to handle pediatric trauma. To overcome these challenges, attention to protocolized care and treatment adaptation based on resource availability is critical. Training in management of trauma helps to reduce the mortality and morbidity in pediatric polytrauma cases. There is also a need for more collaborative research to develop preventative measures to childhood trauma.
Collapse
Affiliation(s)
- Abdelbasit E Ali
- Department of Pediatric Surgery, King Saud Medical City, KSA, Associate Professor of Surgery, Faculty of Medicine, University of Khartoum, Sudan
| | - Shilpa Sharma
- MCh, PhD, ATLS Faculty, ISTPF(UK), FIAPS, MNAMS, FAMS. Professor of Pediatric Surgery, Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Olumide A Elebute
- College of Medicine, University of Lagos and Lagos University Teaching Hospital Idi Araba, Lagos, Nigeria
| | - Adesoji Ademuyiwa
- Department of Surgery, College of Medicine, University of Lagos & Honorary Consultant and Chief Pediatric Surgery Unit, Lagos University Teaching Hospital. Lagos, Nigeria
| | - Noxolo Z Mashavave
- Department of Pediatric Surgery, East London Hospital Complex, Walter Sisulu University, East London, Eastern Cape, South Africa
| | - Milind Chitnis
- Department of Pediatric Surgery, East London Hospital Complex, Walter Sisulu University, East London, Eastern Cape, South Africa
| | | | | |
Collapse
|
14
|
Nzasabimana P, Ignatowicz A, Alayande BT, Abdul-Latif AM, Odland ML, Davies J, Bekele A, Byiringiro JC. Barriers to equitable access to quality trauma care in Rwanda: a qualitative study. BMJ Open 2023; 13:e075117. [PMID: 37770259 PMCID: PMC10546151 DOI: 10.1136/bmjopen-2023-075117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVES Using the 'Four Delay' framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients', caregivers' and community leaders' perspectives. DESIGN A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically. SETTING This qualitative study was conducted in Rwanda's rural Burera District, located in the Northern Province, and in Kigali City, the country's urban capital, to capture both the rural and urban population's experiences of being injured. PARTICIPANTS Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders. RESULTS Multiple barriers were identified cutting across all levels of the 'Four Delays' framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients. CONCLUSIONS Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation.
Collapse
Affiliation(s)
- Pascal Nzasabimana
- Single Project Implementation Unit, University of Rwanda, Kigali, Rwanda
| | | | - Barnabas Tobi 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, Massachusetts, USA
| | | | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa
- 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
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
| | - Jean Claude Byiringiro
- School of Medicine and Pharmacy, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| |
Collapse
|
15
|
Cockburn N, Flood D, Seiglie JA, Manne-Goehler J, Aryal K, Karki K, Damasceno A, Atun R, Vollmer S, Bärnighausen T, Geldsetzer P, Mayige M, Hirschhorn L, Davies J. Health service readiness to provide care for HIV and cardiovascular disease risk factors in low- and middle-income countries. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002373. [PMID: 37738224 PMCID: PMC10516419 DOI: 10.1371/journal.pgph.0002373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/18/2023] [Indexed: 09/24/2023]
Abstract
Cardiovascular disease risk factors (CVDRF), in particular diabetes and hypertension, are chronic conditions which carry a substantial disease burden in Low- and Middle-Income Countries. Unlike HIV, they were neglected in the Millenium Development Goals along with the health services required to manage them. To inform the level of health service readiness that could be achieved with increased attention, we compared readiness for CVDRF with that for HIV. Using data from national Service Provision Assessments, we describe facility-reported readiness to provide services for CVDRF and HIV, and derive a facility readiness score of observed essential components to manage them. We compared HIV vs CVDRF coverage scores by country, rural or urban location, and facility type, and by whether or not facilities reported readiness to provide care. We assessed the factors associated with coverage scores for CVDRF and HIV in a multivariable analysis. In our results, we include 7522 facilities in 8 countries; 86% of all facilities reported readiness to provide services for CVDRF, ranging from 77-98% in individual countries. For HIV, 30% reported of facilities readiness to provide services, ranging from 3-63%. Median derived facility readiness score for CVDRF was 0.28 (IQR 0.16-0.50), and for HIV was 0.43 (0.32-0.60). Among facilities which reported readiness, this rose to 0.34 (IQR 0.18-0.52) for CVD and 0.68 (0.56-0.76) for HIV. Derived readiness scores were generally significantly lower for CVDRF than for HIV, except in private facilities. In multivariable analysis, odds of a higher readiness score in both CVDRF or HIV care were higher in urban vs rural and secondary vs primary care; facilities with higher CVDRF scores were significantly associated with higher HIV scores. Derived readiness scores for HIV are higher than for CVDRF, and coverage for CVDRF is significantly higher in facilities with higher HIV readiness scores. This suggests possible benefits from leveraging HIV services to provide care for CVDRF, but poor coverage in rural and primary care facilities threatens Sustainable Development Goal 3.8 to provide high quality universal healthcare for all.
Collapse
Affiliation(s)
- Neil Cockburn
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - David Flood
- Department of Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jacqueline A. Seiglie
- Department of Medicine, Diabetes Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Krishna Aryal
- Public Health Development Organization, Kathmandu, Nepal
| | - Khem Karki
- Department of Community Medicine, Maharajganj Medical College, Institute of Medicine, Kathmandu, Nepal
| | | | - Rifat Atun
- Department of Global Health & Population, Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sebastian Vollmer
- Center for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Pascal Geldsetzer
- Department of Medicine, Division of Primary Care and Population Health, Stanford University, Stanford, California, United States of America
- Chan Zuckerberg Biohub, San Francisco, California, United States of America
| | - Mary Mayige
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Lisa Hirschhorn
- Ryan Family Center on Global Primary Care, Feinberg School of Medicine, Northwestern University, Chicago, Ilinois, United States of America
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
16
|
van den Akker A, Fabbri A, Alardah DI, Gilmore AB, Rutter H. The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review. Health Res Policy Syst 2023; 21:69. [PMID: 37415182 DOI: 10.1186/s12961-023-01020-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/15/2023] [Indexed: 07/08/2023] Open
Abstract
CONTEXT Participatory systems mapping is increasingly used to gain insight into the complex systems surrounding non-communicable diseases (NCDs) and their risk factors. OBJECTIVES To identify and synthesize studies that used participatory systems mapping in the context of non-communicable diseases. DESIGN Scoping review. ELIGIBILITY CRITERIA Peer-reviewed studies published between 2000 and 2022. STUDY SELECTION Studies that focused on NCDs and/or related risk factors, and included participants at any stage of their system's mapping process, were included. CATEGORIES FOR ANALYSIS The main categories for analysis were: (1) problem definition and goal-setting, (2) participant involvement, (3) structure of the mapping process, (4) validation of the systems map, and (5) evaluation of the mapping process. RESULTS We identified 57 studies that used participatory systems mapping for a variety of purposes, including to inform or evaluate policies or interventions and to identify potential leverage points within a system. The number of participants ranged from 6 to 590. While policymakers and professionals were the stakeholder groups most often included, some studies described significant added value from including marginalized communities. There was a general lack of formal evaluation in most studies. However, reported benefits related mostly to individual and group learning, whereas limitations described included a lack of concrete actions following from systems mapping exercises. CONCLUSIONS Based on the findings of this review, we argue that research using participatory systems mapping would benefit from considering three different but intertwined actions: explicitly considering how different participants and the power imbalances between them may influence the participatory process, considering how the results from a systems mapping exercise may effectively inform policy or translate into action, and including and reporting on evaluation and outcomes of the process, wherever possible.
Collapse
|
17
|
Whitaker J, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard RF, Leather AJM, Davies J. Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi. BMJ Open 2023; 13:e070900. [PMID: 37263691 PMCID: PMC10255326 DOI: 10.1136/bmjopen-2022-070900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/21/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi. DESIGN Facilitated group process mapping workshops with summary process mapping synthesis. SETTING Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi. PARTICIPANTS Fifty-four healthcare workers from various cadres took part. RESULTS An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities). CONCLUSIONS We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.
Collapse
Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- 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, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Abena S Amoah
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Health Office, Karonga, Malawi
- Department of Pathology, School of Medicine & Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Boston Munthali
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
- Department of Orthopaedic Surgery, Mzuzu Central Hospital, Mzuzu, Malawi
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M 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, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- 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 Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
| |
Collapse
|
18
|
Owolabi EO, Nyamathe S, Joseph C, Khuabi LAJN, English RG, Vlok A, Erasmus E, Geduld HI, Lategan HJ, Chu KM. Mapping access to care and identification of barriers for traumatic brain injury in a South African township. J Eval Clin Pract 2023; 29:380-391. [PMID: 36415056 DOI: 10.1111/jep.13793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022]
Abstract
RATIONALE South Africa has a high traumatic injury burden resulting in a significant number of persons suffering from traumatic brain injury (TBI). TBI is a time-sensitive condition requiring a responsive and organized health system to minimize morbidity and mortality. This study outlined the barriers to accessing TBI care in a South African township. METHODS This was a multimethod study. A facility survey was carried out on health facilities offering trauma care in Khayelitsha township, Cape Town, South Africa. Perceived barriers to accessing TBI care were explored using qualitative interviews and focus group discussions. The four-delay framework that describes delays in four phases was used: seeking, reaching, receiving, and remaining in care. We purposively recruited individuals with a history of TBI (n = 6) and 15 healthcare professionals working with persons with TBI (seven individuals representing each of the five facilities, the heads of neurosurgery and emergency medical services and eight additional healthcare providers who participated in the focus group discussions). Quantitative data were analysed descriptively while qualitative data were analysed thematically, following inductive and deductive approaches. FINDINGS Five healthcare facilities (three community health centres, one district hospital and one tertiary hospital) were surveyed. We conducted 13 individual interviews (six with persons with TBI history, seven with healthcare providers from each of the five facilities, neurosurgery department and emergency medical service heads and two focus group discussions involving eight additional healthcare providers. Participants mentioned that alcohol abuse and high neighbourhood crime could lead to delays in seeking and reaching care. The most significant barriers reported were related to receiving definitive care, mostly due to a lack of diagnostic imaging at community health centres and the district hospital, delays in interfacility transfers due to ambulance delays and human and infrastructural limitations. A barrier to remaining in care was the lack of clear communication between persons with TBI and health facilities regarding follow-up care. CONCLUSION Our study revealed that various individual-level, community and health system factors impacted TBI care. Efforts to improve TBI care and reduce injury-related morbidity and mortality must put in place more community-level security measures, institute alcohol regulatory policies, improve access to diagnostics and invest in hospital infrastructures.
Collapse
Affiliation(s)
- Eyitayo O Owolabi
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa.,Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Samukelisiwe Nyamathe
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa
| | - Conran Joseph
- Department of Health and Rehabilitation Sciences, Division of Occupational therapy, Stellenbosch University, Cape Town, South Africa
| | - Lee-Ann Jacobs-Nzuzi Khuabi
- Department of Health and Rehabilitation Sciences, Division of Occupational therapy, Stellenbosch University, Cape Town, South Africa
| | - Rene G English
- Department of Global Health, Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
| | - Adriaan Vlok
- Division of Neurosurgery, Stellenbosch University, Cape Town, South Africa
| | - Elaine Erasmus
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Heike I Geduld
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Hendrick J Lategan
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Kathryn M Chu
- Department of Global Health, Centre for Global Surgery, Stellenbosch University, Cape Town, South Africa.,Department of Surgery, University of Botswana, Gaborone, Botswana
| |
Collapse
|
19
|
Social Determinants of Seeking and Reaching Injury Care in South Africa: A Community-Based Qualitative Study. Ann Glob Health 2023; 89:5. [PMID: 36743285 PMCID: PMC9881434 DOI: 10.5334/aogh.4003] [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: 11/01/2022] [Accepted: 12/16/2022] [Indexed: 01/28/2023] Open
Abstract
Background Timely access to quality injury care saves lives and prevents disabilities. The impact of social determinants of health on the high injury prevalence in South Africa is well documented, however, evidence of their role in accessing injury care is lacking. This study explored the social determinants of seeking and reaching injury care in South Africa. Methods This was a qualitative study involving rural and urban patients, community members, and healthcare providers in Western Cape, South Africa. Data were obtained through semi-structured interviews and focus group discussions using an interview guide informed by the four-delays framework. Inductive and deductive approaches were used for thematic analysis. Results A total of 20 individual interviews and 5 focus group discussions were conducted. There were 28 males (individual interviews: 13; focus groups: 15) and 22 females (individual interviews: 7; focus groups: 15), and their mean age was 41 (standard deviation ±15) years. Barriers to seeking and reaching injury care cut across five social determinants of health domains: healthcare access and quality; neighbourhood and environment; social and community context; education; and economic stability. The most prominent social determinants of seeking and reaching injury care were related to healthcare access and quality, including perceived poor healthcare quality, poor attitude of healthcare workers, long waiting time, and ambulance delays. However, there was a strong interconnection between these and neighbourhood and environmental determinants such as safety concerns, high crime rates, gangsterism, lack of public transportation, and social and community factors (presence/absence of social support and alcohol use). Barriers related to education and economic stability were less prevalent. Conclusion We found a substantial role of neighbourhood, social, and community factors in seeking and reaching injury care. Therefore, efforts aimed at improving access to injury care and outcomes must go beyond addressing healthcare factors to include other social determinants and should involve collaborations with multiple sectors, including the community, the police, the transport department, and alcohol regulation agencies.
Collapse
|
20
|
Mac Quene T, Smith L, Odland ML, Levine S, D'Ambruoso L, Davies J, Chu K. Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop. Glob Health Action 2022; 15:2067395. [PMID: 35730572 PMCID: PMC9225684 DOI: 10.1080/16549716.2022.2067395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. OBJECTIVE To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. METHODS A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. RESULTS Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. CONCLUSIONS This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.
Collapse
Affiliation(s)
- Tamlyn Mac Quene
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Luné Smith
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maria Lisa Odland
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Susan Levine
- Department of Anthropology, Humanities Faculty, University of Cape Town, Cape Town, South Africa
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Justine Davies
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Institute for Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
21
|
Reuter A, Rogge L, Monahan M, Kachapila M, Morton DG, Davies J, Vollmer S. Global economic burden of unmet surgical need for appendicitis. Br J Surg 2022; 109:995-1003. [PMID: 35881506 PMCID: PMC10364778 DOI: 10.1093/bjs/znac195] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/27/2022] [Accepted: 05/12/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. METHODS Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. RESULTS Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and $73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and $75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. CONCLUSION For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially.
Collapse
Affiliation(s)
- Anna Reuter
- Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Lisa Rogge
- Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
- Institute of Economics, Department of Health Economics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Mark Monahan
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Mwayi Kachapila
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Dion G Morton
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Justine Davies
- Correspondence to: (J.D.) Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK (e-mail: ); (S.V.) Department of Economics & Centre for Modern Indian Studies (CeMIS), University of Goettingen, Waldweg 26, 37073 Göttingen, Germany (e-mail: )
| | - Sebastian Vollmer
- Correspondence to: (J.D.) Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK (e-mail: ); (S.V.) Department of Economics & Centre for Modern Indian Studies (CeMIS), University of Goettingen, Waldweg 26, 37073 Göttingen, Germany (e-mail: )
| |
Collapse
|
22
|
Evaluating Post-Injury Functional Status among Patients Presenting for Emergency Care in Kigali, Rwanda. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite high injury-related morbidity, approaches for evaluating post-injury functional status after emergency care are poorly characterized in resource-limited settings. This study evaluated the feasibility of standardized disability assessments among patients presenting with significant trauma to the Centre Hospitalier Universitaire de Kigali ED in Rwanda from January–June 2020. The functional status at 28-days post-injury was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2), the Katz Activities of Daily Living (ADL) Scale, and self-reported functional state. The primary outcome was a descriptive profile of the disability status at 28-days post-injury. The WHODAS 2.0, Katz ADL Scale and patients’ self-perceived functional status was compared using Kendall’s rank correlation coefficient. Twenty-four patients were included. The most common injury mechanism was road traffic accident (70.8%); 58.3% of patients had traumatic brain injury. The self-perception questionnaire and the Katz ADL scale were strongly correlated with the WHODAS 2.0 scale; however, self-perception was not well correlated with the ADL scale. Post-injury morbidity was high and morbidity assessment was feasible, with a strong correlation between patients’ self-perceived functional status and the WHODAS-2 scale. Structured post-injury assessments may serve to inform the development of rehabilitation services in Rwanda, although larger studies are needed to inform such initiatives.
Collapse
|
23
|
Goldberg EM, Bountogo M, Harling G, Baernighausen T, Davies JI, Hirschhorn LR. Older persons experiences of healthcare in rural Burkina Faso: Results of a cross sectional household survey. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000193. [PMID: 36962344 PMCID: PMC10021992 DOI: 10.1371/journal.pgph.0000193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/18/2022] [Indexed: 11/19/2022]
Abstract
Ensuring responsive healthcare which meets patient expectations and generates trust is important to increase rates of access and retention. This need is important for aging populations where non-communicable diseases (NCDs) are a growing cause of morbidity and mortality. We performed a cross-sectional household survey including socio-demographic; morbidities; and patient-reported health system utilization, responsiveness, and quality outcomes in individuals 40 and older in northwestern Burkina Faso. We describe results and use exploratory factor analysis to derive a contextually appropriate grouping of health system responsiveness (HSR) variables. We used linear or logistic regression to explore associations between socio-demographics, morbidities, and the grouped-variable, then between these variables and health system quality outcomes. Of 2,639 eligible respondents, 26.8% had least one NCD, 56.3% were frail or pre-frail and 23.9% had a recent healthcare visit, including only 1/3 of those with an NCD. Highest ratings of care experience (excellent/very good) included ease of following instructions (86.1%) and trust in provider skills (81.1%). The HSR grouping with the greatest factor loading included involvement in decision-making, clarity in communication, trust in the provider, and confidence in providers' skills, labelled Shared Understanding and Decision Making (SUDM). In multivariable analysis, higher quality of life (OR 1.02,95%CI 1.01-1.04), frailty (OR 1.47,95%CI 1.00-2.16), and SUDM (OR 1.06,95%CI 1.05-1.09) were associated with greater health system trust and confidence. SUDM was associated with overall positive assessment of the healthcare system (OR 1.02,95%CI 1.01-1.03) and met healthcare needs (OR 1.09,95%CI 1.08-1.11). Younger age and highest wealth quintile were also associated with higher met needs. Recent healthcare access was low for people with existing NCDs, and SUDM was the most consistent factor associated with higher health system quality outcomes. Results highlight the need to increase continuity of care for aging populations with NCDs and explore strengthening SUDM to achieve this goal.
Collapse
Affiliation(s)
- Ellen M. Goldberg
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States of America
| | | | - Guy Harling
- Institute for Global Health, University College London, London, United Kingdom
| | - Till Baernighausen
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Justine I. Davies
- Institute of Applied Health Research, Birmingham University, Birmingham, United Kingdom
| | - Lisa R. Hirschhorn
- Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
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.
Collapse
|
26
|
Odland ML, Abdul-Latif AM, Ignatowicz A, Alayande B, Appia Ofori B, Balanikas E, Bekele A, Belli A, Chu K, Ferreira K, Howard A, Nzasabimana P, Owolabi EO, Nyamathe S, Pognaa Kunfah SM, Tabiri S, Yakubu M, Whitaker J, Byiringiro JC, Davies JI. Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa. BMJ Glob Health 2022; 7:bmjgh-2021-008256. [PMID: 35410954 PMCID: PMC9003614 DOI: 10.1136/bmjgh-2021-008256] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 02/18/2022] [Indexed: 11/23/2022] Open
Abstract
Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.
Collapse
Affiliation(s)
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK .,Department of Obstetrics and Gynecology, St. Olavs University Hospital, Trondheim, Norway.,Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
| | - Abdul-Malik Abdul-Latif
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Volta Regional Health Directorate, Ghana Health Service, Accra, Greater Accra, Ghana
| | | | - 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, Massachusetts, USA
| | | | | | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda.,Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Antonio Belli
- University of Birmingham, Birmingham, UK.,National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.,Department of Surgery, University of Botswana, Gaborone, Botswana
| | - Karen Ferreira
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Anthony Howard
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Centre, University of Oxford, Headington, Oxford, UK
| | | | - Eyitayo O Owolabi
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Samukelisiwe Nyamathe
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | | | - Stephen Tabiri
- Ghana HUB of NIHR Global Surgery, Tamale, Ghana.,Department of Public Health, Tamale Teaching Hospital, Tamale, Ghana.,Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Mustapha Yakubu
- Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana.,School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana
| | - John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Jean Claude Byiringiro
- University of Rwanda, Kigali, Rwanda.,Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.,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
| |
Collapse
|
27
|
Uwamahoro C, Gonzalez Marques C, Beeman A, Mutabazi Z, Twagirumukiza FR, Jing L, Ndebwanimana V, Uwamahoro D, Nkeshimana M, Tang OY, Naganathan S, Jarmale S, Stephen A, Aluisio AR. Injury burdens and care delivery in relation to the COVID-19 pandemic in Kigali, Rwanda: A prospective interrupted cross-sectional study. Afr J Emerg Med 2021; 11:422-428. [PMID: 34513579 PMCID: PMC8415735 DOI: 10.1016/j.afjem.2021.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/07/2021] [Accepted: 06/26/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction Injuries cause significant burdens in sub-Saharan Africa. In Rwanda, national regulations to reduce COVID-19 altered population mobility and resource allocations. This study evaluated epidemiological trends and care among injured patients preceding and during the COVID-19 pandemic at the Centre Hospitalier Universitaire de Kigali (CHUK) in Kigali, Rwanda. Methods This prospective interrupted cross-sectional study enrolled injured adult patients (≥15 years) presenting to the CHUK emergency department (ED) from January 27th-March 21st (pre-COVID-19 period) and June 1st-28th (intra-COVID-19 period). Trained study personnel continuously collected standardized data on enrolled participants through the first six-hours of ED care. The Kampala Trauma Score (KTS) was calculated as a metric of injury severity. Case characteristics prior to and during the pandemic were compared, statistical differences were assessed using χ2 or Fisher's exact tests. Results Data were collected from 409 pre-COVID-19 and 194 intra-COVID-19 cases. Median age was 32, with a male predominance (74.3%). Road traffic injuries (RTI) were the most common injury mechanism pre-COVID-19 (47.8%) and intra-COVID-19 (53.6%) (p = 0.27). There was a significant increase in the number of transfer cases during the intra-COVID-19 period (52.1%) versus pre-COVID-19 (41.3%) (p = 0.01). KTS was significantly lower among intra-COVID-19 patients (p = 0.04), indicating higher severity of presentation. In the intra-COVID-19 period, there was a significant increase in the number of surgery consultations (40.7%) versus pre-COVID-19 (26.7%) (p < 0.001). The number of hospital admissions increased from 35.5% pre-COVID-19 to 46.4% intra-COVID-19 (p = 0.01). There was no significant mortality difference pre-COVID-19 as compared to the intra-COVID-19 period among injured patients (p = 0.76). Conclusion Emergency injury care showed increased injury burden, inpatient admission and resource requirements during the pandemic period. This suggests the spectrum of disease may be more severe and that greater resources for injury management may continue to be needed during the ongoing COVID-19 pandemic in Rwanda and other similar settings.
Collapse
Affiliation(s)
- Chantal Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | | | - Aly Beeman
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Zeta Mutabazi
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | | | - Ling Jing
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vincent Ndebwanimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Doris Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Menelas Nkeshimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Oliver Y. Tang
- Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sonya Naganathan
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Spandana Jarmale
- Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Andrew Stephen
- Brown University Warren Alpert Medical School, Department of Surgery, Providence, RI, USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
- Brown University Warren Alpert Medical School, Providence, RI, USA
| |
Collapse
|
28
|
Velin L, Donatien M, Wladis A, Nkeshimana M, Riviello R, Uwitonze JM, Byiringiro JC, Ntirenganya F, Pompermaier L. Systematic media review: A novel method to assess mass-trauma epidemiology in absence of databases-A pilot-study in Rwanda. PLoS One 2021; 16:e0258446. [PMID: 34644363 PMCID: PMC8513851 DOI: 10.1371/journal.pone.0258446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/27/2021] [Indexed: 12/23/2022] Open
Abstract
Objective Surge capacity refers to preparedness of health systems to face sudden patient inflows, such as mass-casualty incidents (MCI). To strengthen surge capacity, it is essential to understand MCI epidemiology, which is poorly studied in low- and middle-income countries lacking trauma databases. We propose a novel approach, the “systematic media review”, to analyze mass-trauma epidemiology; here piloted in Rwanda. Methods A systematic media review of non-academic publications of MCIs in Rwanda between January 1st, 2010, and September 1st, 2020 was conducted using NexisUni, an academic database for news, business, and legal sources previously used in sociolegal research. All articles identified by the search strategy were screened using eligibility criteria. Data were extracted in a RedCap form and analyzed using descriptive statistics. Findings Of 3187 articles identified, 247 met inclusion criteria. In total, 117 MCIs were described, of which 73 (62.4%) were road-traffic accidents, 23 (19.7%) natural hazards, 20 (17.1%) acts of violence/terrorism, and 1 (0.09%) boat collision. Of Rwanda’s 30 Districts, 29 were affected by mass-trauma, with the rural Western province most frequently affected. Road-traffic accidents was the leading MCI until 2017 when natural hazards became most common. The median number of injured persons per event was 11 (IQR 5–18), and median on-site deaths was 2 (IQR 1–6); with natural hazards having the highest median deaths (6 [IQR 2–18]). Conclusion In Rwanda, MCIs have decreased, although landslides/floods are increasing, preventing a decrease in trauma-related mortality. By training journalists in “mass-casualty reporting”, the potential of the “systematic media review” could be further enhanced, as a way to collect MCI data in settings without databases.
Collapse
Affiliation(s)
- Lotta Velin
- Department of Biomedical and Clinical Sciences, Center for Teaching & Research in Disaster Medicine and Traumatology (KMC), Linköping University, Linköping, Sweden
- * E-mail:
| | | | - Andreas Wladis
- Department of Biomedical and Clinical Sciences, Center for Teaching & Research in Disaster Medicine and Traumatology (KMC), Linköping University, Linköping, Sweden
| | | | - Robert Riviello
- Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
| | | | | | - Faustin Ntirenganya
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- University Teaching Hospital in Kigali, Kigali, Rwanda
| | - Laura Pompermaier
- Department of Biomedical and Clinical Sciences, Center for Teaching & Research in Disaster Medicine and Traumatology (KMC), Linköping University, Linköping, Sweden
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America
| |
Collapse
|
29
|
Carey TA. Solving the Puzzle of Global Health Inequity: Completing the Picture Piece by Piece by Piece. ACTA ACUST UNITED AC 2021; 1:195-208. [PMID: 34622214 PMCID: PMC8397854 DOI: 10.1007/s43477-021-00022-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022]
Abstract
Achieving health equity is an ongoing priority for the global community. Understanding, supporting, and addressing the challenges that face health workers is a critical component of the solution to this problem. The University of Global Health Equity (UGHE) in Rwanda has established the Institute of Global Health Equity Research (IGHER) to contribute to the generation of new knowledge through high-quality research and research training that seeks to improve our understanding of the important issues that influence the distribution of health and healthcare globally. With an unrelenting emphasis on increased impact by prioritizing implementation research, IGHER is particularly interested in amassing a compendium of important research lessons to increase the likelihood that effective implementation strategies will be employed to enhance healthcare service provision. IGHER organizes research according to five foundational research questions, which address different elements that are pivotal to a comprehensive approach to appreciating the nuanced realities of effective healthcare service provision. UGHE outputs for 2020 indicate that: appropriate resourcing of healthcare services is critical for the eradication of global health inequities; policy reform is required for many healthcare innovations and initiatives to be implemented adequately; and high-quality research that is applicable to different contexts is essential for eradicating global health inequities. Furthermore, reimagining healthcare delivery will benefit from an intentional, ongoing, bidirectional influence between evidence-based pedagogy (methods and practices of teaching, education, and instruction) and supporting research activity such that education and instruction inform the research conducted and research findings are fed back to the classroom to help improve education and instruction. As IGHER continues to grow, the valuable insights afforded by high-impact implementation research will increase. These insights will help to inform the development and use of evidence-based implementation strategies for the adoption, scaling, and sustainability of equitable, effective, and efficient health services globally.
Collapse
Affiliation(s)
- Timothy A Carey
- Institute of Global Health Equity Research, University of Global Health Equity, PO Box 6955, Kigali, 20093 Rwanda
| |
Collapse
|
30
|
Breedt DS, Odland ML, Bakanisi B, Clune E, Makgasa M, Tarpley J, Tarpley M, Munyika A, Sheehama J, Shivera T, Biccard B, Boden R, Chetty S, de Waard L, Duys R, Groeneveld K, Levine S, Mac Quene T, Maswime S, Naidoo M, Naidu P, Peters S, Reddy CL, Verhage S, Muguti G, Nyaguse S, D'Ambruoso L, Chu K, Davies JI. Identifying knowledge needed to improve surgical care in Southern Africa using a theory of change approach. BMJ Glob Health 2021; 6:bmjgh-2021-005629. [PMID: 34130990 PMCID: PMC8208008 DOI: 10.1136/bmjgh-2021-005629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022] Open
Abstract
Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: ‘An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]’ and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond.
Collapse
Affiliation(s)
- Danyca Shadé Breedt
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Balisi Bakanisi
- Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Edward Clune
- Department of Anaesthesia, University of Botswana, Gaborone, Botswana
| | | | - John Tarpley
- Department of Surgery, University of Botswana, Gabarone, Botswana
| | - Margaret Tarpley
- Department of Medical Education, University of Botswana, Gaborone, Botswana
| | - Akutu Munyika
- Department of Surgery, University of Namibia, Windhoek, Namibia.,Department of Surgery, Onandjokwe Lutheran Hospital, Oniipa, Namibia
| | | | | | - Bruce Biccard
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Regan Boden
- Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Sean Chetty
- Anaesthesiology and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Liesl de Waard
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rowan Duys
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Kristin Groeneveld
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Susan Levine
- Department of Anthropology, Humanities Faculty, University of Cape Town, Cape Town, South Africa
| | - Tamlyn Mac Quene
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Salome Maswime
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Megan Naidoo
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Priyanka Naidu
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Shrikant Peters
- Executive Management, Groote Schuur Hospital, Department of Public Health and Familiy Medicine, University of Cape Town, Cape Town, South Africa
| | - Ché L Reddy
- Harvard Medical School, Boston, Massachusetts, USA
| | - Savannah Verhage
- Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Godfrey Muguti
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shingai Nyaguse
- Division of Anaesthesia, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Kathryn Chu
- Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Centre for Global Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,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
| | | |
Collapse
|
31
|
Whitaker J, Harling G, Sie A, Bountogo M, Hirschhorn LR, Manne-Goehler J, Bärnighausen T, Davies J. Non-fatal injuries in rural Burkina Faso amongst older adults, disease burden and health system responsiveness: a cross-sectional household survey. BMJ Open 2021; 11:e045621. [PMID: 34049913 PMCID: PMC8166610 DOI: 10.1136/bmjopen-2020-045621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the epidemiology of injury as well as patient-reported health system responsiveness following injury and how this compares with non-injured patient experience, in older individuals in rural Burkina Faso. DESIGN Cross-sectional household survey. Secondary analysis of the CRSN Heidelberg Ageing Study dataset. SETTING Rural Burkina Faso. PARTICIPANTS 3028 adults, over 40, from multiple ethnic groups, were randomly sampled from the 2015 Nouna Health and Demographic Surveillance Site census. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was incidence of injury. Secondary outcomes were incidence of injury related disability and patient-reported health system responsiveness following injury. RESULTS 7.7% (232/3028) of the population reported injury in the preceding 12 months. In multivariable analyses, younger age, male sex, highest wealth quintile, an abnormal Generalised Anxiety Disorder score and lower Quality of Life score were all associated with injury. The most common mechanism of injury was being struck or hit by an object, 32.8%. In multivariable analysis, only education was significantly negatively associated with odds of disability (OR 0.407, 95% CI 0.17 to 0.997). Across all survey participants, 3.9% (119/3028) reported their most recent care seeking episode was following injury, rather than for another condition. Positive experience and satisfaction with care were reported following injury, with shorter median wait times (10 vs 20 min, p=0.002) and longer consultation times (20 vs 15 min, p=0.002) than care for another reason. Injured patients were also asked to return to health facilities more often than those seeking care for another reason, 81.4% (95% CI 73.1% to 87.9%) vs 54.8% (95% CI 49.9% to 53.6%). CONCLUSIONS Injury is an important disease burden in this older adult rural low-income and middle-income country population. Further research could inform preventative strategies, including safer rural farming methods, explore the association between adverse mental health and injury, and strengthen health system readiness to provide quality care.
Collapse
Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Guy Harling
- Institute for Global Health, University College London, London, UK
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospitals, University of Heidelberg, Heidelberg, Germany
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| |
Collapse
|
32
|
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: 30] [Impact Index Per Article: 10.0] [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.
Collapse
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
| |
Collapse
|
33
|
Umutesi G, Davies J, Hedt-Gauthier BL. We Asked the Experts: Global Surgery-Seeing Beyond the Silo. World J Surg 2020; 44:3595-3596. [PMID: 32812135 PMCID: PMC7433675 DOI: 10.1007/s00268-020-05747-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Grace Umutesi
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Justine Davies
- Institute for Applied Research, University of Birmingham, Birmingham, B15 2TT, UK. .,Department of Global Health, Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa.
| | - Bethany L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| |
Collapse
|