In the line of duty: a study of ambulance drivers during the 2010 conflict in Kashmir

A Review of Ambulance Terrorism on the African Continent

BACKGROUND

In recent decades, an increasing number of terrorist attacks have been carried out against medical institutions, hospitals, and health care workers. These attacks, that often result in high numbers of casualties and impaired access to health services, have a more significant impact on people's sense of security than attacks against military and police targets. Attacks on ambulances - especially on the African continent - have been sparsely studied. This study examines attacks on ambulances on the African continent during the period from 1992-2022 (until December 31, 2021).

METHODS

Reports of ambulance terrorism were extracted from the Global Terrorism Database (GTD), RAND Database of Worldwide Terrorism Incidents (RDWTI), United Nation's Safeguarding Health in Conflict Coalition (SHCC) database, Armed Conflict Location and Event Data Project (ACLED), Surveillance System for Attacks on Health Care (SSA) database, and Aid Worker Security Database (AWSD). Furthermore, a grey literature search was performed. The date and location of the attacks, perpetrators, weapon and attack types, and the number of victims (dead and wounded) and hostages were collected. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

RESULTS

During the 30-year study period, 166 attacks were observed in 18 African countries. The number of attacks significantly increased since 2016, with 81.3% of the attacks taking place from 2016 to 2022. In total, 193 people died and another 208 were injured. Attacks with firearms were most frequently noted (92 cases; 55.4%), followed by attacks with explosive devices (26 cases; 15.7%). A significant number of ambulances were hijacked (26 cases; 15.7%) and subsequently used for other terrorist attacks. In seven attacks, ambulances were used as vehicle-born improvised explosive devices (VBIEDs).

CONCLUSION

In this database study on ambulance terrorism in Africa, it was found that the reported occurrence of attacks increased from 2013 onwards, including the rise of ambulances used as VBIEDs. These findings suggest that ambulance terrorism represents a real, significant risk that both governments and health care institutions must address.

Barriers and facilitators to cardiopulmonary resuscitation within pre-hospital emergency medical services: a qualitative study

Background

Out-of-hospital cardiopulmonary arrest is a common and fatal problem. Rescuing patients with this problem by pre-hospital emergency medical services is associated with various barriers and facilitators. Identifying these barriers as well as the facilitators in a qualitative and an information-rich way will help to improve the quality of performing the maneuver and to increase the patients’ survival. Therefore, the current study was qualitatively conducted with the aim of identifying the factors affecting the cardiopulmonary resuscitation within the pre-hospital emergency medical services.

Methods

This qualitative study was conducted using a content analysis approach in Iran in 2021. The participants were 16 Iranian emergency medical technicians who were selected through a purposive sampling method. For data collection, in-depth and semi-structured interviews were conducted. For data analysis, the Elo and Kyngäs method was applied.

Results

The mean participants’ age was 33.06 ± 7.85 years, and their mean work experience was 10.62 ± 6.63 years. The collected information was categorized into one main category called “complex context of the cardiopulmonary resuscitation” and 5 general categories with 17 subcategories. These categories and subcategories include patient condition (patient’s underlying diseases, age, high weight, number of children, and place of living), dominant atmosphere in companions at home (companions’ feeling of agitation, companions doing harm, and companions helping), policy (educational policy, human resource policy, up-to-date equipment and technology, and do-not-resuscitate policy), performance of the out-of-organizational system (disorganization in the patient handover process, and cooperation of the support organizations), and conditions related to the treatment team (conscience, cultural dominance, and shift burden).

Conclusions

The results showed that the conditions related to the patient and his/her companions, as well as the organizational factors such as the policies and the out-of-organizational factors act as the barriers and the facilitators to the cardiopulmonary resuscitation within pre-hospital emergency medical services. Therefore, the barriers can be modified and the facilitators can be enhanced by taking various measures such as educating, human resource policy-making, upgrading the equipment, and considering appropriate management policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00514-3.

Violence against healthcare in conflict: a systematic review of the literature and agenda for future research

BACKGROUND

Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward.

METHODS AND FINDINGS

This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data.

CONCLUSION

Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.

Iranian Nurses' Experiences of Workplace Violence in Prehospital Emergency Care: A Qualitative Study

Prehospital emergency care nurses experience severe workplace violence. However, despite the widespread violence they experience, this phenomenon has not been well studied among these nurses. Therefore, the purpose of this study was to explore the experiences of Iranian nurses working in prehospital setting regarding workplace violence with a focus on the factors leading to such violence. In this qualitative descriptive study, 23 prehospital nurses participated purposefully. The data were collected by individual face-to-face semistructured interviews and analyzed using content analysis methodology. Data analysis led to the identification of 4 main themes, including job competency mismatch, inadequate resources, criticality of the situation and circumstances, and inadequate awareness and misplaced expectations of society. These nurses have not completed specialized training courses, work in a system that is in a critical situation, and face many barriers and deficiencies in terms of intra- and interorganizational coordination. On the other hand, people in the community do not have sufficient awareness about the duties and services provided by prehospital nurses and thus have unrealistic expectations to receive services. The results showed that there was a deep gap between the prehospital emergency realities and public expectations, leading to workplace violence. Therefore, efforts to improve the working conditions of nurses with an emphasis on teaching specialized prehospital emergency courses, especially violence control courses, promoting intra- and interorganizational coordination, and increasing the equipment and personnel of ambulances for special missions, as well as raising the public awareness and outlining more realistic expectations, may reduce the prevalence of violence against prehospital nurses.

Iranian pre-hospital emergency care nurses' strategies to manage workplace violence: A descriptive qualitative study

AIM

To explore the experiences of Iranian nurses working in pre-hospital emergency care services and the strategies used to manage of workplace violence.

BACKGROUND

Pre-hospital emergency nurses are subject to workplace violence; however, little research addresses their experiences, particularly related to their strategies in dealing with workplace violence.

METHODS

A descriptive qualitative study that involved nineteen male nurses who were working in pre-hospital services collected data using semi-structured interviews and analysed it using qualitative content analysis.

RESULTS

Data analysis yielded four descriptive categories including no reaction to violence (tolerance and acceptance as common workplace conflicts), situational management (patient and scene management), confrontation (direct and indirect) and escaping the scene. Patient management was the dominant strategy used and had the best outcomes related to both patient and personnel safety.

CONCLUSION

This study showed that pre-hospital nurses use different strategies to manage violence and patient management was a common and useful strategy for managing workplace violence. However, the pre-hospital nurses have little training, insufficient support and are poorly prepared to manage workplace violence.

IMPLICATIONS FOR NURSING MANAGEMENT

The development of context-based guidelines, continuing education, better-equipped ambulances that include medical and defence equipment, as well as better coordination of the police force in ambulance operations, can help to reduce workplace violence.

Violence against emergency medical services personnel: A systematic review of the literature

BACKGROUND

Violence against emergency medical services (EMS) personnel is a growing concern. The aim of this systematic review is to synthesize the current literature on violence against EMS personnel.

METHODS

We examined literature from 2000 to 2016. Eligibility criteria included English-language, peer-reviewed studies of EMS personnel that described violence or assaults. Sixteen searches identified 2655 studies; 25 studies from nine countries met the inclusion criteria.

RESULTS

The evidence from this review demonstrates that violence is a common risk for EMS personnel. We identified three critical topic areas: changes in risk over time, economic impact of violence and, outcomes of risk-reduction interventions. There is a lack of peer reviewed research of interventions, with the result that current intervention programs have no reliable evidence base.

CONCLUSIONS

EMS leaders and personnel should work together with researchers to design, implement, evaluate and publish intervention studies designed to mitigate risks of violence to EMS personnel.

Public-private implementation of integrated emergency response services: Case study of GVK Emergency Management and Research Institute in Karnataka, India

BACKGROUND

Emergency medical services are important to the functioning of health systems, but these services tend to be neglected in low- and middle-income countries, such as India. In recent years, several models of pre-hospital emergency medical services have emerged in India. Research on these models holds important lessons for existing and future emergency medical service programs in low- and middle-income countries. Our objective was to provide a comprehensive description of the organizational structure and service delivery model of a public-private partnership in the southern Indian state of Karnataka, GVK Emergency Management and Research Institute, with a particular focus on its operations in Bengaluru.

METHODS

A case study methodology was used to explore systematically the organizational model of GVK Emergency Management and Research Institute in Karnataka. Qualitative data were collected through an in-person site visit to GVK Emergency Management and Research Institute headquarters in Bengaluru in July 2013. Three sources were used: in-depth, semistructured interviews, document review, and nonparticipant observation. Data were analyzed according to the health system "building blocks" proposed by the World Health Organization.

RESULTS

The organization follows a standardized model across the states and union territories where they have contractual arrangements, including Karnataka. Processes for fleet maintenance, information systems/information technology and training, and deployment were well structured at the organizational level. The public-private partnership appears pro-poor in orientation; however, further demand-side research is required on the perspective of patients.

CONCLUSION

Our study reveals a functional structure at the organizational level, which provides a key service at no cost to users. Detailed analyses of this nature can help inform global efforts for the development and strengthening of emergency medical services systems.

Vulnerabilities of Local Healthcare Providers in Complex Emergencies: Findings from the Manipur Micro-level Insurgency Database 2008-2009

Background: Research on healthcare delivery in zones of conflict requires sustained and systematic attention. In the context of the South Asian region, there has been an absence of research on the vulnerabilities of health care workers and institutions in areas affected by armed conflict. The paper presents a case study of the varied nature of security challenges faced by local healthcare providers in the state of Manipur in the North-eastern region of India, located in the Indo-Myanmar frontier region which has been experiencing armed violence and civil strife since the late 1960s. . The aim of this study was to assess longitudinal and spatial trends in incidents involving health care workers in Manipur during the period 2008 to 2009. Methods: We conducted a retrospective database analysis of the Manipur Micro-level Insurgency Database 2008-2009, created by using local newspaper archives to measure the overall burden of violence experienced in the state over a two year period. Publicly available press releases of armed groups and local hospitals in the state were used to supplement the quantitative data. Simple linear regression was used to assess longitudinal trends. Data was visualized with GIS-software for spatial analysis. Results: The mean proportion of incidents involving health care workers per month was 2.7% and ranged between 0 and 6.1% (table 2). There was a significant (P=0.037) month-to-month variation in the proportion of incidents involving health care workers, as well as a upward trend of about 0.11% per month. Spatial analysis revealed different patterns depending on whether absolute, population-adjusted, or incident-adjusted frequencies served as the basis of the analysis. Conclusions: The paper shows a small but steady rise in violence against health workers and health institutions impeding health services in Manipur’s pervasive violence. More evidence-building backed by research along with institutional obligations and commitment is essential to protect the health-systems Keywords: India, Manipur, insurgency, healthcare, security, ethnic strife