Community-based perceptions of emergency care in communities lacking formalised emergency medicine systems by Morgan Broccoli BRCMOR002 Submitted to the University of Cape Town In fulfilment of the requirements for the degree Master of Science (Med) in Emergency Medicine Faculty of Health Sciences UNIVERSITY OF CAPE TOWN University of Cape Town Date of submission: 28 January 2015 Supervisor: Professor Lee Wallis Head: Division of Emergency Medicine University of Cape Town The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town DECLARATION I, Morgan Broccoli, hereby declare that the work on which this thesis is based is my original work (except where acknowledgements indicate otherwise) and that neither the whole work nor any part of it has been, is being, or is to be submitted for another degree in this or any other university. I empower the university to reproduce for the purpose of research either the whole or any portion of the contents in any manner whatsoever. Signature: Signature removed Date: 28 January 2015 ACKNOWLEDGEMENTS There are many people who proved to be invaluable in the implementation of this project. First, I would like to thank my supervisor Lee Wallis for his support and guidance throughout the entire process. Michele Twomey and Charmaine Cunningham were my co-investigators in Zambia, and the Zambia course would not have been possible without them. The Zambian Defence Force and the Zambian Ministry of Health were instrumental in driving this project in Zambia, and Anne Mumbi was the key to organising all of the stakeholders. David Ndhlovu, Geoffrey Sandala, Nelson Lombe, Emmanuel Jonga, Alex Musweu, and Esther Sakala were our Zambian colleagues who did a fantastic job as focus group facilitators; they truly made the data collection possible. When the project moved to Kenya, Emilie Calvello and Benjamin Wachira became critical parts of the investigatory team, and together with Alex Skog and Mary Li assisted me with running the Kenyan project and training course. Benjamin Wachira was also instrumental when making logistical plans. Our Kenyan team consisted of Lisa Mudola, Lydia Ogunde, Javan Kado, and Irungu Wangechi, and they did a fantastic job of facilitating the focus groups and collecting and translating the data. Again, this project would not have been possible without each of our wonderful focus group facilitators. Finally, I would like to acknowledge the American International Health Alliance for supporting the project in Zambia, and the University of Maryland and Johns Hopkins University for supporting the project in Kenya. ABSTRACT Background Kenya and Zambia face an increasing burden of emergent disease, with a high incidence of communicable diseases, increasing prevalence of non-communicable diseases and traumatic injuries. However, neither country has an integrated emergency care system that provides community access to high-quality emergency services. There has been recent interest in strengthening the emergency care systems in these countries, but before any interventions are implemented, an assessment of the current need for emergency care must be conducted, as the burden of acute disease and barriers to accessing emergency care in Zambia and Kenya remain largely undocumented. Aims and Objectives The aim of this project was to ascertain community-based perceptions of the critical interventions necessary to improve access to emergency care in Zambia and Kenya, with the following objectives: 1. Determine the current pattern of out-of-hospital emergency care delivery at the community level. 2. Identify the communities’ experiences with emergency conditions and the barriers they face when trying to access care. 3. Discover community-generated solutions to the paucity of emergency care in urban and rural settings. Methods Semi-structured focus groups were piloted in Zambia with 200 participants. Results were analysed with subsequent tool refinement for Kenya. Data were collected via focus groups with 600 urban and rural community members in cities and rural villages in the 8 Kenyan provinces. Thematic analysis of community member focus groups identified frequency of emergencies, perceptions of emergency care, perceived barriers to emergency care, and ideas for potential interventions. Results Analysis of the focus group data identified several common themes. Community members in Zambia and Kenya experience a wide range of medical emergencies, and they rely on family members, neighbours, and Good Samaritans for assistance. These community members frequently provide assistance with transportation to medical facilities, and also attempt some basic first aid. These communities are already assisting one another during emergencies, and are willing to help in the future. Participants in this study also identified several barriers to emergency care: a lack of community education, absent or non-functional communication systems, insufficient transportation, no triage system, a lack of healthcare providers trained in emergency care, and inadequate equipment and supplies. Conclusions Community members in Zambia and Kenya experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Creating community education initiatives, identifying novel transportation solutions, implementing triage in healthcare facilities, and improving receiving facility care were community-identified solutions to barriers to emergency care. TABLE OF CONTENTS Acronyms and Abbreviations i List of Tables ii List of Figures iii List of Appendices iv Chapter 1: Introduction 1 1.1 Background 1 1.1.1 Zambia 2 1.1.2 Status of Emergency Care in Zambia 4 1.1.3 Kenya 5 1.1.4 Status of Emergency Care in Kenya 7 1.1.5 Integrating Acute and Emergency Care into Health Systems 8 1.2 Motivation 9 1.3 Aims and Objectives 10 1.4 Summary 11 Chapter 2: Literature Review 13 2.1 Emergency Care in Zambia 14 2.2 Emergency Care in Kenya 16 2.3 Needs Assessments 17 2.4 Barriers to Access 21 2.5 Community First Response 24 Chapter 3: Methodology 27 3.1 Focus Group Methodology 27 3.2 Focus Group Interviews, Zambia 29 3.2.1 Design 29 3.2.2 Focus Group Script 29 3.2.3 Facilitator Training 30 3.2.4 Setting 31 3.2.5 Population 32 3.2.6 Sampling Strategy 32 3.2.7 Data Collection 33 3.2.8 Data Analysis 33 3.3 Focus Group Interviews, Kenya 34 3.3.1 Design 34 3.3.2 Focus Group Script 35 3.3.3 Facilitator Training 36 3.3.4 Setting 37 3.3.5 Population 38 3.3.6 Sampling Strategy 38 3.3.7 Data Collection 39 3.3.8 Data Analysis 39 3.4 Ethical Considerations 40 3.4.1 Risk to Participants 40 3.4.2 Benefit to Participants 41 Chapter 4: Findings 42 4.1 Introduction 42 4.2 Community Exposure to Medical Emergencies in Zambia 43 4.3 Assistance and Willingness to Help in Zambia 46 4.4 Barriers to Emergency Care in Zambia 47 4.5 Community-Identified Solutions in Zambia 49 4.6 Healthcare Providers in Zambia 50 4.6.1 Provider-Identified Barriers to Emergency Care 54 4.6.2 Provider-Identified Solutions 57 4.7 Community Exposure to Medical Emergencies in Kenya 61 4.8 Assistance and Willingness to Help in Kenya 65 4.9 Barriers to Emergency Care in Kenya 69 4.9.1 Factors that make it easier to access emergency care in Kenya 71 4.10 Community-Identified Solutions in Kenya 72 Chapter 5: Discussion 76 5.1 Introduction 76 5.2 Community Exposure to Medical Emergencies 77 5.3 Assistance and Willingness to Help 82 5.4 How Emergency Care is Currently Delivered 85 5.5 Barriers to Emergency Care 87 5.6 Community-Identified Solutions 90 5.7 Limitations of the Study 96 Chapter 6: Conclusion 99 Chapter 7: Recommendations 100 7.1 Next Steps 100 References 102 Appendices 117 ACRONYMS AND ABBREVIATIONS AFEM The African Federation for Emergency Medicine CPR Cardio-Pulmonary Resuscitation DALY Disability-Adjusted Life Year DCP Disease Control Priorities in developing countries EMS Emergency Medical Services IFEM The International Federation for Emergency Medicine KEPH Kenya Essential Package for Health LMIC Low- and Middle-Income Country MoH Ministry of Health MOPHS Ministry of Public Health and Sanitation NCD Non-Communicable Disease NGO Non-Governmental Organisation RTI Road Traffic Incident SOP Standard Operating Procedure WHO World Health Organisation ZDF Zambian Defence Force i LIST OF TABLES Table 1. Zambian health workers per 1,000 people 3 Table 2: Barriers to accessing health services 24 Table 3: Kenyan Urban Centres and Rural Centres 37 Table 4: Kenyan focus groups 43 Table 5: Zambian exposure to medical emergencies 44 Table 6: Zambian emergencies 44 Table 7: Kenyan exposure to medical emergencies 62 Table 8: Kenyan emergencies 62 Table 9: Kenyan transportation 64 Table 10: Kenyans providing assistance 65 Table 11: Assistance provided in Kenya 65 Table 12: Willingness to assist in Kenya 66 ii LIST OF FIGURES Figure 1: KEPH levels of care 6 Figure 2: Framework for the study of access 22 iii LIST OF APPENDICES Appendix 1: Zambia Script 1 117 Appendix 2: Zambia Script 2 119 Appendix 3: Kenya Script 120 Appendix 4: Zambia Proposal 123 Appendix 5: Zambia Approval 136 Appendix 6: Kenya Proposal 137 Appendix 7: Kenya Approval 150 Appendix 8: Zambia Consent 152 Appendix 9: Kenya