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Spencer SA, Rutta A, Hyuha G, Banda GT, Choko A, Dark P, Hertz JT, Mmbaga BT, Mfinanga J, Mijumbi R, Muula A, Nyirenda M, Rosu L, Rubach M, Salimu S, Sakita F, Salima C, Sawe H, Simiyu I, Taegtmeyer M, Urasa S, White S, Yongolo NM, Rylance J, Morton B, Worrall E, Limbani F. Multimorbidity-associated emergency hospital admissions: a "screen and link" strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol. NIHR OPEN RESEARCH 2024; 4:2. [PMID: 39145104 PMCID: PMC11320189 DOI: 10.3310/nihropenres.13512.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 08/16/2024]
Abstract
Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub-Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng'ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.
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Affiliation(s)
- Stephen A. Spencer
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Alice Rutta
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Gimbo Hyuha
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gift Treighcy Banda
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | | | - Paul Dark
- Humanitarian and Conflict Response Institute, The University of Manchester, Manchester, England, UK
| | - Julian T. Hertz
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | | | - Juma Mfinanga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rhona Mijumbi
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Adamson Muula
- The Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Laura Rosu
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Matthew Rubach
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | - Sangwani Salimu
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Francis Sakita
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Hendry Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ibrahim Simiyu
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Miriam Taegtmeyer
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Sarah Urasa
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Sarah White
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Nateiya M. Yongolo
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Ben Morton
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Eve Worrall
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - MultiLink Consortium
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Humanitarian and Conflict Response Institute, The University of Manchester, Manchester, England, UK
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
- The Kamuzu University of Health Sciences, Blantyre, Malawi
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Achikondi Women Community Clinic, Lilongwe, Malawi
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Profitt LB, Bresick G, Rossouw L, Van Stormbroek B, Ras T, Von Pressentin K. Healthcare access for children in a low-income area in Cape Town: A mixed-methods case study. S Afr Fam Pract (2004) 2023; 65:e1-e12. [PMID: 38197687 PMCID: PMC10784270 DOI: 10.4102/safp.v65i1.5754] [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: 03/28/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND In Cape Town, the under-5 mortality rate has plateaued to 20 per 1000 live births, with 60% of child deaths occurring out of hospital. The southern subdistrict has the largest paediatric population in Metro West and accounts for 31% of deaths. This study aimed to uncover the access barriers and facilitators underlying this high burden of out-of-hospital deaths. METHODS An exploratory mixed-methods case study design employed three data collection strategies: a quantitative survey with randomly sampled community members, semi-structured interviews with purposively sampled caregivers whose children presented critically ill or deceased (January 2017 - December 2020) and a nominal group technique (NGT) to build solution-oriented consensus among purposively sampled health workers, representing different levels of care in the local health system. RESULTS A total of 62 community members were surveyed, 11 semi-structured caregiver interviews were conducted, and 11 health workers participated in the NGT. Community members (74%) experienced barriers in accessing care. Knowledge of basic home care for common conditions was limited. Thematic analysis of interviews showed affordability, acceptability, and access, household and facility factor barriers. The NGT suggested improvement in community-based services, transport access and lengthening service hours would facilitate access. CONCLUSION While multiple barriers to accessing care were identified, facilitators addressing these barriers were explored. Healthcare planners should examine the barriers within their geographic areas of responsibility to reduce child deaths.Contribution: This study uncovers community perspectives on childhood out-of-hospital deaths and makes consensus-based recommendations for improvement.
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Affiliation(s)
- Luke B Profitt
- Department of Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town; and Western Cape Government Health and Wellness, Cape Town.
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Neill S, Bray L, Carter B, Roland D, Carrol ED, Bayes N, Riches L, Hughes J, Pandey P, O'Donnell J, Palmer-Hill S. Navigating uncertain illness trajectories for young children with serious infectious illness: a modified grounded theory study. BMC Health Serv Res 2022; 22:1103. [PMID: 36042434 PMCID: PMC9427158 DOI: 10.1186/s12913-022-08420-5] [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: 02/22/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background Infectious illness is the biggest cause of death in children due to a physical illness, particularly in children under five years. If mortality is to be reduced for this group of children, it is important to understand factors affecting their pathways to hospital. The aim of this study was to retrospectively identify organisational and environmental factors, and individual child, family, and professional factors affecting timing of admission to hospital for children under five years of age with a serious infectious illness (SII). Methods An explanatory modified grounded theory design was used in collaboration with parents. Two stages of data collection were conducted: Stage 1, interviews with 22 parents whose child had recently been hospitalised with a SII and 14 health professionals (HPs) involved in their pre-admission trajectories; Stage 2, focus groups with 18 parents and 16 HPs with past experience of SII in young children. Constant comparative analysis generated the explanatory theory. Results The core category was ‘navigating uncertain illness trajectories for young children with serious infectious illness’. Uncertainty was prevalent throughout the parents’ and HPs’ stories about their experiences of navigating social rules and overburdened health services for these children. The complexity of and lack of continuity within services, family lives, social expectations and hierarchies provided the context and conditions for children’s, often complex, illness trajectories. Parents reported powerlessness and perceived criticism leading to delayed help-seeking. Importantly, parents and professionals missed symptoms of serious illness. Risk averse services were found to refer more children to emergency departments. Conclusions Parents and professionals have difficulties recognising signs of SII in young children and can feel socially constrained from seeking help. The increased burden on services has made it more difficult for professionals to spot the seriously ill child. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08420-5.
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Affiliation(s)
- Sarah Neill
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Devon, UK.,Faculty of Science, Charles Sturt University, Bathurst, Australia
| | - Lucy Bray
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, Lancashire, UK
| | - Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, Lancashire, UK.,Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK.,SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Natasha Bayes
- Faculty of Health, Education and Society, University of Northampton, Northampton, Northamptonshire, UK.
| | - Lucie Riches
- Support Services, Meningitis Now, Gloucestershire, Stroud, UK
| | - Joanne Hughes
- Mother's Instinct and Harmed Patients Alliance, Cambridgeshire, UK
| | - Poornima Pandey
- Department of Paediatrics, Kettering General Hospital NHS Foundation Trust, Kettering, Northamptonshire, UK
| | - Jennifer O'Donnell
- Human Factors and Investigation, London City University, Cranfield University, London Cranfield, Bedfordshire, UK
| | - Sue Palmer-Hill
- Northamptonshire Healthcare NHS Foundation Trust, Northampton, Northamptonshire, UK
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Ghavi A, Hassankhani H, Powers K, Arshadi-Bostanabad M, Namdar-Areshtanab H, Heidarzadeh M. Parental support needs during pediatric resuscitation: A systematic review. Int Emerg Nurs 2022; 63:101173. [DOI: 10.1016/j.ienj.2022.101173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 11/05/2022]
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Ghavi A, Hassankhani H, Powers K, Arshadi-Bostanabad M, Namdar Areshtanab H, Heidarzadeh M. Parents' and healthcare professionals' experiences and perceptions of parental readiness for resuscitation in Iranian paediatric hospitals: a qualitative study. BMJ Open 2022; 12:e055599. [PMID: 35613813 PMCID: PMC9131064 DOI: 10.1136/bmjopen-2021-055599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine parents' and healthcare professionals' experiences and perceptions of parental readiness for resuscitation of their child in a paediatric hospital. DESIGN This exploratory descriptive qualitative study used content analysis. Participants shared their experiences and perceptions about parental readiness for cardiopulmonary resuscitation through semi-structured and in-depth interviews. MAXQDA 2020 software was also used for data analysis. SETTING The setting was two large teaching paediatric hospitals in Iran (Este Azerbaijan and Mashhad). PARTICIPANTS Participants were 10 parents and 13 paediatric healthcare professionals (8 nurses and 5 physicians). Selection criteria were: (a) parents who experienced their child's resuscitation crisis at least 3 months prior and (b) nurses and physicians who were working in emergency rooms or intensive care wards with at least 2 years of experience on the resuscitation team. RESULTS Participants shared their experiences about parental readiness for resuscitation of their child in four categories: awareness (acceptance of resuscitation and its consequences; providing information about the child's current condition and prognosis), chaos in providing information (defect of responsibility in informing; provide selective protection of information; hardness in obtaining information), providing situational information (honest information on the border of hope and hopeless; providing information with apathy; providing information as individual; dualism in blaming; assurance to parents; presence of parents to better understand the child's situation) and psychological and spiritual requirements (reliance on supernatural power; need for access to a psychologist; sharing emotions; collecting mementos). CONCLUSION The results of this study provide insight on the needs of parents and strategies to use to prepare them for their child's resuscitation crisis, which can be used to enhance family centred care practices in paediatric acute care settings.
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Affiliation(s)
- Arezoo Ghavi
- Student Research Committee, Department of Pediatric Nursing, School of Nursing and Midwifery, Tabriz, The Islamic Republic of Iran
| | - Hadi Hassankhani
- Road Traffic Injury Research Center, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, The Islamic Republic of Iran
| | - Kelly Powers
- School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Mohammad Arshadi-Bostanabad
- Department of Pediatric Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, The Islamic Republic of Iran
| | - Hossein Namdar Areshtanab
- Department of Psychology Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, The Islamic Republic of Iran
| | - Mohammad Heidarzadeh
- Department of Pediatric Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, The Islamic Republic of Iran
- Department of Neonatology, Tabriz University of Medical Sciences, Tabriz, Iran
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Limbani F, Kabajaasi O, Basemera M, Gooding K, Kenya-Mugisha N, Mkandawire M, Rusoke D, Jacob ST, Katahoire AR, Rylance J. Facilitating high quality acute care in resource-constrained environments: Perspectives of patients recovering from sepsis, their caregivers and healthcare workers in Uganda and Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000272. [PMID: 36962705 PMCID: PMC10021962 DOI: 10.1371/journal.pgph.0000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/08/2022] [Indexed: 11/19/2022]
Abstract
Sepsis is a major global health problem, especially in sub-Saharan Africa. Improving patient care requires that healthcare providers understand patients' priorities and provide quality care within the confines of the context they work. We report the perspectives of patients, caregivers and healthcare workers regarding care quality for patients admitted for sepsis to public hospitals in Uganda and Malawi. This qualitative descriptive study in two hospitals included face-to face semi-structured interviews with purposively selected patients recovering from sepsis, their caregivers and healthcare workers. In both Malawi and Uganda, sepsis care often occurred in resource-constrained environments which undermined healthcare workers' capacity to deliver safe, consistent and accessible care. Constraints included limited space, strained; water, sanitation and hygiene (WASH) amenities and practices, inadequate human and material resources and inadequate provision for basic needs including nutrition. Heavy workloads for healthcare workers strained relationships, led to poor communication and reduced engagement with patients and caregivers. These consequences were exacerbated by understaffing which affected handover and continuity of care. All groups (healthcare workers, patients and caregivers) reported delays in care due to long queues and lack of compliance with procedures for triage, treatment, stabilization and monitoring due to a lack of expertise, supervision and context-specific sepsis management guidelines. Quality sepsis care relies on effective severity-based triaging, rapid treatment of emergencies and individualised testing to confirm diagnosis and monitoring. Hospitals in resource-constrained systems contend with limitations in key resources, including for space, staff, expertise, equipment and medicines, in turn contributing to gaps in areas such as WASH and effective care delivery, as well as communication and other relational aspects of care. These limitations are the predominant challenges to achieving high quality care.
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Affiliation(s)
- Felix Limbani
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | - Kate Gooding
- Oxford Policy Management, Oxford, United Kingdom
| | | | - Mercy Mkandawire
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Shevin T Jacob
- Walimu, Kampala, Uganda
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Jamie Rylance
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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A Qualitative Exploration of the Referral Process of Children with Common Infections from Private Low-Level Health Facilities in Western Uganda. CHILDREN 2021; 8:children8110996. [PMID: 34828709 PMCID: PMC8618635 DOI: 10.3390/children8110996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/23/2022]
Abstract
Over 50% of sick children are treated by private primary-level facilities, but data on patient referral processes from such facilities are limited. We explored the perspectives of healthcare providers and child caretakers on the referral process of children with common childhood infections from private low-level health facilities in Mbarara District. We carried out 43 in-depth interviews with health workers and caretakers of sick children, purposively selected from 30 facilities, until data saturation was achieved. The issues discussed included the process of referral, challenges in referral completion and ways to improve the process. We used thematic analysis, using a combined deductive/inductive approach. The reasons for where and how to refer were shaped by the patients’ clinical characteristics, the caretakers’ ability to pay and health workers’ perceptions. Caretaker non-adherence to referral and inadequate communication between health facilities were the major challenges to the referral process. Suggestions for improving referrals were hinged on procedures to promote caretaker adherence to referral, including reducing waiting time and minimising the expenses incurred by caretakers. We recommend that triage at referral facilities should be improved and that health workers in low-level private health facilities (LLPHFs) should routinely be included in the capacity-building trainings organised by the Ministry of Health (MoH) and in workshops to disseminate health policies and national healthcare guidelines. Further research should be done on the effect of improving communication between LLPHFs and referral health facilities by affordable means, such as telephone, and the impact of community initiatives, such as transport vouchers, on promoting adherence to referral for sick children.
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South African paramedic perspectives on prehospital palliative care. BMC Palliat Care 2020; 19:153. [PMID: 33032579 PMCID: PMC7545550 DOI: 10.1186/s12904-020-00663-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Background Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. Methods A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. Results Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. Conclusion Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.
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Carter B, Roland D, Bray L, Harris J, Pandey P, Fox J, Carrol ED, Neill S. A systematic review of the organizational, environmental, professional and child and family factors influencing the timing of admission to hospital for children with serious infectious illness. PLoS One 2020; 15:e0236013. [PMID: 32702034 PMCID: PMC7377491 DOI: 10.1371/journal.pone.0236013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022] Open
Abstract
Background Infection, particularly in the first 5 years of life, is a major cause of childhood deaths globally, many deaths from infections such as pneumonia and meningococcal disease are avoidable, if treated in time. Some factors that contribute to morbidity and mortality can be modified. These include organisational and environmental factors as well as those related to the child, family or professional. Objective Examine what organizational and environmental factors and individual child, family and professional factors affect timing of admission to hospital for children with a serious infectious illness. Design Systematic review. Data sources Key search terms were identified and used to search CINAHL Plus, Medline, ASSIA, Web of Science, The Cochrane Library, Joanna Briggs Institute Database of Systematic Review. Study appraisal methods Primary research (e.g. quantitative, qualitative and mixed methods studies) and literature reviews (e.g., systematic, scoping and narrative) were included if participants included or were restricted to children under 5 years of age with serious infectious illnesses, included parents and/or first contact health care professionals in primary care, urgent and emergency care and where the research had been conducted in OECD high income countries. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies. Main findings Thirty-six papers were selected for full text review; 12 studies fitted the inclusion criteria. Factors influencing the timing of admission to hospital included the variability in children’s illness trajectories and pathways to hospital, parental recognition of symptoms and clinicians non-recognition of illness severity, parental help-seeking behaviour and clinician responses, access to services, use and non-use of ‘gut feeling’ by clinicians, and sub-optimal management within primary, secondary and tertiary services. Conclusions The pathways taken by children with a serious infectious illness to hospital are complex and influenced by a variety of potentially modifiable individual, organisational, environmental and contextual factors. Supportive, accessible, respectful services that provide continuity, clear communication, advice and safety-netting are important as is improved training for clinicians and a mandate to attend to ‘gut feeling’. Implications Relatively simple interventions such as improved communication have the potential to improve the quality of care and reduce morbidity and mortality in children with a serious infectious illness.
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Affiliation(s)
- Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
- * E-mail:
| | - Damian Roland
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Lucy Bray
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Jane Harris
- Faculty of Health, Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | - Poornima Pandey
- Children’s and Adolescent Services, Kettering General Hospital NHS Foundation Trust, Kettering, United Kingdom
| | - Jo Fox
- Faculty of Health & Social Care, University of Chester, Chester, United Kingdom
| | - Enitan D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Sarah Neill
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
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Hodkinson PW, Pigoga JL, Wallis L. Emergency healthcare needs in the Lavender Hill suburb of Cape Town, South Africa: a cross-sectional, community-based household survey. BMJ Open 2020; 10:e033643. [PMID: 31964675 PMCID: PMC7045142 DOI: 10.1136/bmjopen-2019-033643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Emergency care is a key component of healthcare systems, but little is known about its real impact on communities. This study evaluated access, utilisation and barriers to healthcare, and specifically emergency care, in the low socioeconomic Cape Town suburb of Lavender Hill. DESIGN A cross-sectional, community-based household survey. SETTING Lavender Hill suburb in the Cape Flats of Cape Town, South Africa. PARTICIPANTS Two-stage cluster sampling was used to identify approximately 13 households in each of 46 clusters, for a total of 608 households. A senior householder responded on behalf of each household surveyed. PRIMARY OUTCOME MEASURES Access to, utilisation of and unmet needs related to healthcare at large and emergency care. RESULTS In August 2018, 608 households were surveyed, encompassing 2754 individuals, with a response rate of 96.4%. Almost a quarter of respondents (n=663, 24.1%) used the healthcare system within the last year. Female gender, advancing age, lower levels of education, recipients of disability grants, smaller household sizes and living in formal dwellings were factors associated with increased risk of unmet healthcare and emergency care needs. Only a small proportion of respondents (n=39, 1.4%) reported having unmet emergency healthcare needs, with wait times at facilities (n=9, 23.1%), emergency medical service delays (n=7, 17.9%) and personal safety (n=6, 15.4%) being prominent. There was a high prevalence of chronic medical conditions (hypertension, diabetes and dyslipidaemias) and recent deaths predominantly from trauma and malignancy. CONCLUSION The emergency healthcare needs of the community appear to be well catered for, although community expectations may not be high and many barriers exist, particularly in accessing emergency care-be it via ambulance services or at healthcare facilities-and caring for chronic diseases in the ageing population. The Lavender Hill community could benefit from programmes addressing chronic disease management and emergency care delivery within the community.
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Affiliation(s)
- Peter W Hodkinson
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
| | - Jennifer Lee Pigoga
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
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Dekker-Boersema J, Hector J, Jefferys LF, Binamo C, Camilo D, Muganga G, Aly MM, Langa EBR, Vounatsou P, Hobbins MA. Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique. Afr J Emerg Med 2019; 9:172-176. [PMID: 31890479 PMCID: PMC6933270 DOI: 10.1016/j.afjem.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/16/2019] [Accepted: 05/20/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. We implemented a three-colour triage system in a rural district hospital with lay-staff workers conducting the first triage. METHODS A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. RESULTS 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2-40 min). CONCLUSION In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings.
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Affiliation(s)
| | | | | | | | - Deavis Camilo
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Gerard Muganga
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Mussa Manuel Aly
- Operational Research Unit Pemba, Pemba, Cabo Delgado, Mozambique
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Aluisio AR, Waheed S, Cameron P, Hess J, Jacob ST, Kissoon N, Levine AC, Mian A, Ramlakhan S, Sawe HR, Razzak J. Clinical emergency care research in low-income and middle-income countries: opportunities and challenges. BMJ Glob Health 2019; 4:e001289. [PMID: 31406600 PMCID: PMC6666826 DOI: 10.1136/bmjgh-2018-001289] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/05/2019] [Accepted: 01/12/2019] [Indexed: 12/29/2022] Open
Abstract
Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth.
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Affiliation(s)
- Adam R Aluisio
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Shahan Waheed
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jermey Hess
- Department of Emergency Medicine, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Shevin T Jacob
- Division of Allergy and Infectious Diseases, Universityof Washington, Seattlel, WA, United States
| | - Niranjan Kissoon
- Departmentof Pediatrics and Emergency Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Asad Mian
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Shammi Ramlakhan
- Emergency Department, Sheffield Children's Hospital, Sheffield, UK.,Faculty of Medical Sciences, University of the West Indies, Kingston, Jamaica
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Junaid Razzak
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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"She's gone now." A mixed methods analysis of the experiences and perceptions around the deaths of children who died unexpectedly in health care facilities in Cape Town, South Africa. PLoS One 2019; 14:e0213455. [PMID: 30840699 PMCID: PMC6402763 DOI: 10.1371/journal.pone.0213455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/21/2019] [Indexed: 11/19/2022] Open
Abstract
Purpose The sudden death of a child is a catastrophic event for both the family and the healthcare workers involved. Confidential enquiries provide a biomedical depiction of the processes and quality of care delivered and drive improvements in care. However, these rarely include an assessment of the patient/caregiver experience which is increasingly regarded as a key measure of quality of care. Methods A parallel convergent mixed methods design was used to compare and contrast medically-assessed clinical quality of care with caregiver perceptions of quality and care in a cohort of sudden childhood deaths in emergency facilities in Cape Town, South Africa. Results Amongst the 29 sudden childhood deaths, clinical quality of care was assessed as poor in 11 (38%) and the death was considered avoidable or potentially avoidable in 16 (55%). The main themes identified from the caregivers were their perception of the quality of care delivered (driven by perceived healthcare worker effort, empathy and promptness), the way the family was dealt with during the final resuscitation, and communications at the time of and after the death. Ten (35%) caregivers were predominantly negative about the care delivered, of whom four received fair clinical quality of care; 13 (49%) of caregivers had predominantly positive experiences, one of whom received poor clinical quality of care. Conclusions Caregivers’ experiences of the healthcare service around their child’s death are influenced largely by the way healthcare workers communicate with them, as well as the perceived clinical effort. This is not always concordant with the clinically assessed quality of care. Simple interventions such as protocols and education of healthcare workers in dealing with families of a dying or deceased child could improve families’ experiences at a time when they are most vulnerable.
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Jimenez Fernandez R, Corral Liria I, Rodriguez Vázquez R, Cabrera Fernandez S, Losa Iglesias ME, Becerro de Bengoa Vallejo R. Exploring the knowledge, explanatory models of illness, and patterns of healthcare-seeking behaviour of Fang culture-bound syndromes in Equatorial Guinea. PLoS One 2018; 13:e0201339. [PMID: 30192763 PMCID: PMC6128453 DOI: 10.1371/journal.pone.0201339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/13/2018] [Indexed: 11/18/2022] Open
Abstract
In 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) included "culture-bound syndromes" in its classification of psychiatric disorders and associated them with disease processes that manifest in behavioural or thought disorders that develop within a given cultural context. This study examines the definitions, explanatory models, signs and symptoms, and healthcare-seeking behaviours common to Fang culture-bound syndromes (i.e., kong, eluma, witchcraft, mibili, mikug, and nsamadalu). The Fang ethnic group is the majority ethnic group in Equatorial Guinea. From September 2012 to January 2013, 45 key Fang informants were selected, including community leaders, tribal elders, healthcare workers, traditional healers, and non-Catholic pastors in 39 of 724 Fang tribal villages in 6 of 13 districts in the mainland region of Equatorial Guinea. An ethnographic approach with an emic-etic perspective was employed. Data were collected using semi-structured interviews, participant observation and a questionnaire that included DHS6 key indicators. Interviews were designed based on the Cultural Formulation form in the DSM-5 and explored the definition of Fang cultural syndromes, symptoms, cultural perceptions of cause, and current help-seeking. Participants defined "Fang culture-bound syndromes" as those diseases that cannot be cured, treated, or diagnosed by science. Such syndromes present with the same signs and symptoms as diseases identified by Western medicine. However, they arise because of the actions of enemies, because of the actions of spirits or ancestors, as punishments for disregarding the law of God, because of the violation of sexual or dietary taboos, or because of the violation of a Fang rite of passage, the dzas, which is celebrated at birth. Six Fang culture-bound syndromes were included in the study: 1) Eluma, a disease that is targeted at the victim out of envy and starts out with sharp, intense, focussed pain and aggressiveness; 2) Witchcraft, characterized by isolation from the outside, socially maladaptive behaviour, and the use of hallucinogenic substances; 3) Kong, which is common among the wealthy class and manifests as a disconnection from the environment and a lack of vital energy; 4) Mibili, a possession by evil spirits that manifests through visual and auditory hallucinations; 5) Mikug, which appears after a person has had contact with human bones in a ritual; and 6) Nsamadalu, which emerges after a traumatic process caused by violating traditions through having sexual relations with one's sister or brother. The therapeutic resources of choice for addressing Fang culture-bound syndromes were traditional Fang medicine and the religious practices of the Bethany and Pentecostal churches, among others. Among African ethnic groups, symbolism, the weight of tradition, and the principle of chance in health and disease are underlying factors in the presentation of certain diseases, which in ethno-psychiatry are now referred to as culture-bound syndromes. In this study, traditional healers, elders, healthcare professionals, religious figures, and leaders of the Fang community in Equatorial Guinea referred to six such cultural syndromes: eluma, witchcraft, kong, mibili, mikug, and nsamadalu. In the absence of a multidisciplinary approach to mental illness in the country, the Fang ethnic group seeks healthcare for culture-bound syndromes from traditional healing and religious rites in the Evangelical faiths.
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Affiliation(s)
- Raquel Jimenez Fernandez
- Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. de Atenas, Alcorcón, Madrid, Spain
| | - Inmaculada Corral Liria
- Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. de Atenas, Alcorcón, Madrid, Spain
| | - Rocio Rodriguez Vázquez
- Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. de Atenas, Alcorcón, Madrid, Spain
| | - Susana Cabrera Fernandez
- Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. de Atenas, Alcorcón, Madrid, Spain
| | - Marta Elena Losa Iglesias
- Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avda. de Atenas, Alcorcón, Madrid, Spain
- * E-mail:
| | - Ricardo Becerro de Bengoa Vallejo
- Escuela Universitaria Enfermería, Fisioterapia y Podología, Facultad de Medicina, Universidad Complutense de Madrid, Avenida Complutense, Madrid, Spain
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Argent AC. Considerations for Assessing the Appropriateness of High-Cost Pediatric Care in Low-Income Regions. Front Pediatr 2018; 6:68. [PMID: 29637061 PMCID: PMC5880905 DOI: 10.3389/fped.2018.00068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022] Open
Abstract
It may be difficult to predict the consequences of provision of high-cost pediatric care (HCC) in low- and middle-income countries (LMICs), and these consequences may be different to those experienced in high-income countries. An evaluation of the implications of HCC in LMICs must incorporate considerations of the specific context in that country (population age profile, profile of disease, resources available), likely costs of the HCC, likely benefits that can be gained versus the costs that will be incurred. Ideally, the process that is followed in decision making around HCC should be transparent and should involve the communities that will be most affected by those decisions. It is essential that the impacts of provision of HCC are carefully monitored so that informed decisions can be made about future provision medical interventions.
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Affiliation(s)
- Andrew C Argent
- Paediatric Critical Care, Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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