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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.
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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.
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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
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Whitaker J, Edem I, Togun E, Amoah AS, Dube A, Chirwa L, Munthali B, Brunelli G, Van Boeckel T, Rickard R, Leather AJM, Davies J. Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi. PLoS Med 2024; 21:e1004344. [PMID: 38252654 PMCID: PMC10843098 DOI: 10.1371/journal.pmed.1004344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/05/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings. METHODS AND FINDINGS To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework. CONCLUSIONS By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Idara Edem
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, United States of America
- Michigan State University, East Lansing, Michigan, United States of America
| | - Ella Togun
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Abena S. Amoah
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (formerly Karonga Prevention Study), Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
- School of Medicine & Oral Health, Department of Pathology, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
| | - Giulia Brunelli
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
| | - Thomas Van Boeckel
- Health Geography and Policy Group, ETH Zurich, Zurich, Switzerland
- Center for Disease Dynamics Economics and Policy, Washington, DC, United States of America
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Andrew JM Leather
- King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Dotse-Gborgbortsi W, Nilsen K, Ofosu A, Matthews Z, Tejedor-Garavito N, Wright J, Tatem AJ. Distance is “a big problem”: a geographic analysis of reported and modelled proximity to maternal health services in Ghana. BMC Pregnancy Childbirth 2022; 22:672. [PMID: 36045351 PMCID: PMC9429654 DOI: 10.1186/s12884-022-04998-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background Geographic barriers to healthcare are associated with adverse maternal health outcomes. Modelling travel times using georeferenced data is becoming common in quantifying physical access. Multiple Demographic and Health Surveys ask women about distance-related problems accessing healthcare, but responses have not been evaluated against modelled travel times. This cross-sectional study aims to compare reported and modelled distance by socio-demographic characteristics and evaluate their relationship with skilled birth attendance. Also, we assess the socio-demographic factors associated with self-reported distance problems in accessing healthcare. Methods Distance problems and socio-demographic characteristics reported by 2210 women via the 2017 Ghana Maternal Health Survey were included in analysis. Geospatial methods were used to model travel time to the nearest health facility using roads, rivers, land cover, travel speeds, cluster locations and health facility locations. Logistic regressions were used to predict skilled birth attendance and self-reported distance problems. Results Women reporting distance challenges accessing healthcare had significantly longer travel times to the nearest health facility. Poverty significantly increased the odds of reporting challenges with distance. In contrast, living in urban areas and being registered with health insurance reduced the odds of reporting distance challenges. Women with a skilled attendant at birth, four or more skilled antenatal appointments and timely skilled postnatal care had shorter travel times to the nearest health facility. Generally, less educated, poor, rural women registered with health insurance had longer travel times to their nearest health facility. After adjusting for socio-demographic characteristics, the following factors increased the odds of skilled birth attendance: wealth, health insurance, higher education, living in urban areas, and completing four or more antenatal care appointments. Conclusion Studies relying on modelled travel times to nearest facility should recognise the differential impact of geographic access to healthcare on poor rural women. Physical access to maternal health care should be scaled up in rural areas and utilisation increased by improving livelihoods. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04998-0.
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Bouanchaud P, Macharia PM, Demise EG, Nakimuli D. Comparing modelled with self-reported travel time and the used versus the nearest facility: modelling geographic accessibility to family planning outlets in Kenya. BMJ Glob Health 2022; 7:e008366. [PMID: 35523451 PMCID: PMC9083396 DOI: 10.1136/bmjgh-2021-008366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/19/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Geographic access to family planning (FP) services has been characterised through a variety of proximity metrics. However, there is little evidence on the validity of women's self-reported compared with modelled travel time to an FP outlet, or between different distance measures. METHODS We used data from four urban sites in Kenya. A longitudinal FP outlet census was directly linked with data from cross-sectional FP user surveys. We combined characteristics of outlet visited to obtain FP, transport mode, self-reported travel time and location of households and outlets with data on road networks, elevation, land use and travel barriers within a cost-distance algorithm to compute modelled travel time, route and Euclidean distance between households and outlets. We compared modelled and self-reported travel times, Euclidean and route distances and the use of visited versus nearest facility. RESULTS 931 contraceptive users were directly linked to their FP source. Self-reported travel times were consistently and significantly higher than modelled times, with greater differences for those using vehicles rather than walking. Modelled and Euclidean distances were similar in the four geographies. 20% of women used their nearest FP outlet while 52% went to their nearest outlet when conditional on it offering their most recently used FP method. CONCLUSION In urban areas with high facility density and good road connectivity, over half of FP users visited their nearest outlet with their chosen method available. In these settings, Euclidean distances were sufficient to characterise geographic proximity; however, reported and modelled travel times differed across all sites.
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Affiliation(s)
- Paul Bouanchaud
- Strategy & Insights, Population Services International, Washington, DC, USA
| | - Peter M Macharia
- Population Health Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Eden G Demise
- SRH, Population Services International, Washington, DC, USA
| | - Doreen Nakimuli
- Strategic Information & Learning, Population Services International, Kampala, Uganda
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