Understanding the Health System Utilisation and Reasons for Avoidable Mortality After Fatal Injury Within a Three-Delays Framework in Karonga, Northern Malawi: a Retrospective Analysis of Verbal Autopsy Data

Overview

Journal BMJ Open

Specialty General Medicine

Date 2024 Apr 29

PMID 38684258

Authors

John Whitaker

Idara Edem

Abena S Amoah

Albert Dube

Lucia DAmbruoso

Rory F Rickard

Andy J M Leather

Justine Davies

Affiliations

Soon will be listed here.

Abstract

Objectives: To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care.

Design: Retrospective analysis of existing VA data routinely collected by a demographic surveillance site.

Setting: Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi.

Participants: Fatally injured members of the HDSS.

Primary And Secondary Outcome Measures: The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system.

Results: Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49).

Conclusions: VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.

References

. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392(10159):1736-1788. PMC: 6227606. DOI: 10.1016/S0140-6736(18)32203-7. View

Jat A, Khan M, Zafar H, Raja A, Hoda Q, Rehmani R . Peer review audit of trauma deaths in a developing country. Asian J Surg. 2004; 27(1):58-64. DOI: 10.1016/s1015-9584(09)60247-5. View

El Tayeb S, Abdalla S, Van den Bergh G, Heuch I . Use of healthcare services by injured people in Khartoum State, Sudan. Int Health. 2014; 7(3):183-9. PMC: 4427533. DOI: 10.1093/inthealth/ihu063. View

Thaddeus S, Maine D . Too far to walk: maternal mortality in context. Soc Sci Med. 1994; 38(8):1091-110. DOI: 10.1016/0277-9536(94)90226-7. View

Lashoher A, Schneider E, Juillard C, Stevens K, Colantuoni E, Berry W . Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures. World J Surg. 2016; 41(4):954-962. DOI: 10.1007/s00268-016-3759-8. View

Christie S, Dickson D, Mbeboh S, Embolo F, Chendjou W, Wepngong E . Association of Health Care Use and Economic Outcomes After Injury in Cameroon. JAMA Netw Open. 2020; 3(5):e205171. PMC: 7237963. DOI: 10.1001/jamanetworkopen.2020.5171. View

Sethi D, Aljunid S, Saperi S, Clemens F, Hardy P, Elbourne D . Comparison of the effectiveness of trauma services provided by secondary and tertiary hospitals in Malaysia. Ann Emerg Med. 2006; 49(1):52-61, 61.e1. DOI: 10.1016/j.annemergmed.2006.08.019. View

C Akinkuotu A, Purcell L, Varela C, Hayes A, Charles A . Childhood Drownings: An Opportunity for Injury Prevention in a Resource-Limited Setting. J Trop Pediatr. 2022; 68(5). DOI: 10.1093/tropej/fmac057. View

Wesson H, Stevens K, Bachani A, Mogere S, Akungah D, Nyamari J . Trauma systems in Kenya: a qualitative analysis at the district level. Qual Health Res. 2015; 25(5):589-99. DOI: 10.1177/1049732314562890. View

10.

Chokotho L, Mulwafu W, Jacobsen K, Pandit H, Lavy C . The burden of trauma in four rural district hospitals in Malawi: a retrospective review of medical records. Injury. 2014; 45(12):2065-70. DOI: 10.1016/j.injury.2014.10.001. View

11.

Chokotho L, Mulwafu W, Nyirenda M, Mbomuwa F, Pandit H, Le G . Establishment of trauma registry at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi and mapping of high risk geographic areas for trauma. World J Emerg Med. 2019; 10(1):33-41. PMC: 6264976. DOI: 10.5847/wjem.j.1920-8642.2019.01.005. View

12.

Byass P, Hussain-Alkhateeb L, DAmbruoso L, Clark S, Davies J, Fottrell E . An integrated approach to processing WHO-2016 verbal autopsy data: the InterVA-5 model. BMC Med. 2019; 17(1):102. PMC: 6543589. DOI: 10.1186/s12916-019-1333-6. View

13.

Varela C, Young S, Groen R, Banza L, Mkandawire N, Moen B . Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey. BMC Public Health. 2020; 20(1):1456. PMC: 7519556. DOI: 10.1186/s12889-020-09575-8. View

14.

Pouramin P, Li C, Busse J, Sprague S, Devereaux P, Jagnoor J . Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study. Lancet Glob Health. 2020; 8(5):e711-e720. PMC: 10809849. DOI: 10.1016/S2214-109X(20)30067-X. View

15.

DAmbruoso L, Kahn K, Wagner R, Twine R, Spies B, van der Merwe M . Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality. Glob Health Res Policy. 2017; 1:2. PMC: 5675065. DOI: 10.1186/s41256-016-0002-y. View

16.

OReilly G, Joshipura M, Cameron P, Gruen R . Trauma registries in developing countries: a review of the published experience. Injury. 2013; 44(6):713-21. DOI: 10.1016/j.injury.2013.02.003. View

17.

Wesson H, Boikhutso N, Bachani A, Hofman K, Hyder A . The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence. Health Policy Plan. 2013; 29(6):795-808. PMC: 4153302. DOI: 10.1093/heapol/czt064. View

18.

Henry J, Reingold A . Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2012; 73(1):261-8. DOI: 10.1097/TA.0b013e31824bde1e. View

19.

Edem I, Dare A, Byass P, DAmbruoso L, Kahn K, Leather A . External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study. BMJ Open. 2019; 9(6):e027576. PMC: 6561452. DOI: 10.1136/bmjopen-2018-027576. View

20.

Wong E, Gupta S, Deckelbaum D, Razek T, Kushner A . Prioritizing injury care: a review of trauma capacity in low and middle-income countries. J Surg Res. 2014; 193(1):217-22. DOI: 10.1016/j.jss.2014.08.055. View