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Abstract
Background In Zambia, an increasing burden of acute illness and injury emphasised the necessity of strengthening the national emergency care system.
Objective The objective of this study was to identify critical interventions necessary to improve the Zambian emergency care system by determining the current pattern of emergency care delivery as experienced by members of the community, identifying the barriers faced when trying to access emergency care and gathering community-generated solutions to improve emergency care in their setting.
Methods We used a qualitative research methodology to conduct focus groups with community members and healthcare providers in three Zambian provinces. Twenty-one community focus groups with 183 total participants were conducted overall, split equally between the provinces. An additional six focus groups were conducted with Zambian healthcare providers. Data were coded, aggregated and analysed using the content analysis approach.
Results Community members in Zambia experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Community-identified and provider-identified barriers to emergency care included transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols.
Conclusions Creating community education initiatives, strengthening the formal prehospital emergency care system, implementing triage in healthcare facilities and training healthcare providers in emergency care were community-identified and provider-identified solutions for improving access to emergency care.
- access to care
- care systems
- emergency care systems
- prehospital care
- qualitative research
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Key messages
What is already known on this subject?
Emergency care systems are just beginning to be developed in many limited-resource countries. Recent articles have highlighted the need to integrate emergency care into existing healthcare systems, but there is no consensus on how to accomplish this.
A needs assessment is critical to inform the planning of such systems. Involving community members provides an accurate picture of the current situation and encourages shared ownership.
What might this study add?
A qualitative study using focus groups in Zambia identified several critical areas for intervention to improve the emergency care system, many of which can be implemented at a low cost. Interventions identified as high-impact included: creating community education initiatives, strengthening the formal pre-hospital emergency care system, implementing triage in healthcare facilities, and training healthcare providers in emergency care.
Introduction
In February 2013, a road traffic accident on the Zambian Great East Road killed 58 people, prompting the Zambian Ministry of Health (MoH) to create an action plan to improve emergency response. The MoH highlighted four key local healthcare challenges: lack of emergency care infrastructure, no universal emergency number or central call centre, no provision of prehospital care and a lack of necessary resources and equipment.1 Zambian stakeholders resolved to take immediate action to strengthen national emergency care services.1
The need to integrate emergency care into healthcare systems is receiving increased attention.2–5 It has been estimated that emergency care systems could address 45% of deaths and 36% of disability in low-income and middle-income countries.6 The emphasis of health systems is on health improvement through effective, prioritised services such as timely response to acute illness and injury.2 ,7 ,8 Delays in treating acute injury and illness are known to cause increased morbidity and mortality.9
Zambia's population is over 14 million people, 60% rural. The under-five mortality rate is 89:1000, and the maternal mortality rate is 280:100 000.10 Historically, emphasis has been placed on communicable diseases as a major cause of mortality, but as in the rest of sub-Saharan Africa, non-communicable diseases and injury are on the rise.10 ,11 There are 1956 health facilities, 88% government owned.12 ,13 Zambia has five levels of healthcare facilities; the highest level is the referral hospitals, of which there were six in 2012. The next tier is ‘general’ hospitals; these provide some specialist and intensive care services, and there were 19 in 2012. District hospitals constitute the next tier, and provide basic surgical, medical and obstetric care; there were 84 in 2012. The bottom two tiers are health centres and health posts. In 2012, there were 409 urban health centres, 1131 rural health centres and 307 health posts.12 ,13 Government facilities are operated by either the MoH or the Zambian Defence Force (ZDF), whose facilities serve military personnel and their families as well as the surrounding civilian communities. Civilians comprise up to 80% of ZDF clinic patients, and the ZDF health system accounts for 16% of health services in Zambia.14
In Zambia, emergency medicine is not recognised as a specialty; there are no practicing emergency physicians, and there are no emergency care training programmes. There is no formal prehospital care system. Community members must find their own transportation to the hospital or health centre, and on arrival may be treated by nurses, clinical officers or doctors with a wide range of medical training. Clinical officers are healthcare providers with 3 years of intensive clinical medicine training, who either work independently or alongside doctors. As there is no standardised approach to emergency care, patients are infrequently triaged and are typically seen in the order of arrival, leading to delays in the treatment of acutely ill patients. The MoH and the ZDF are committed to improving emergency care in the country; one of their first steps was to request a project to identify the needs of their citizens.
No comprehensive disease burden data exist for Zambia, and there have been no robust studies investigating how well the current health systems provide emergency care, or how well citizens are able to receive care during emergencies.
To fully assess the healthcare needs of a region, both quantitative and qualitative data are required. An emergency care needs assessment should describe the burden of acute illness and injury, identify risk factors and preceding causes, and identify interventions to reduce morbidity and mortality. Useful quantitative data include local disease epidemiology and basic demographic and geographical data.15 Quantitative, objective data about the distribution and capacity of local healthcare facilities are also important. Qualitative data should come from all stakeholders, including policy makers, healthcare providers and community members, as this encourages shared ownership of resulting projects. This can be empowering for communities, and promoting partnerships and local ownership results in interventions that are more likely to be successful and sustainable.15
We undertook a study to identify the critical interventions necessary for the Zambian emergency care system by gathering information about community members' current need for, and barriers to, care. To achieve this, we sought to determine the current pattern of emergency care delivery as experienced by members of the community, identify the barriers faced when trying to access emergency care and gather community-generated solutions to improve emergency care in their setting.
Methods
There is no publicly accessible tool available for conducting an assessment of emergency care needs in a community. (Calvello EJB, Tenner AG, Broccoli M, et al. Operationalizing Emergency Care Systems in Sub-Saharan Africa: Consensus-Based Recommendations for Health Care Facilities. Submitted for publication.) Therefore, we undertook a qualitative study using focus groups, as they are ideal for exploring complex topics where the goal is to understand what individuals in a community believe or feel, how they interact with a system and why.16 With input from the ZDF and MoH, two focus group scripts were designed to capture both community members' and healthcare providers' opinions about emergency care (see online supplementary appendices 1 and 2). The scripts were piloted in Zambia on three occasions before being introduced to the facilitator group for final revision.
Supplementary appendices
Six Zambian healthcare providers were trained over 2 days to facilitate the focus groups using a guide adapted from the WHO and World Bank manual.17 Facilitators worked in pairs, with one moderator and one observer. After training, facilitators made final adjustments to the scripts based on their knowledge of local culture. Each pair travelled to one of three Zambian provinces (urban-Copperbelt, rural-Central, mixed-Eastern), selected by the ZDF and the MoH due to increasing reports of trauma.
The investigators worked with facilitators to identify several sites in each community where focus groups could be held. Between 5 and 10 participants were selected using convenience sampling at each site.16 Convenience sampling was used because we did not have access to census data, which would be required for probability sampling techniques. Facilitators attempted to reduce potential bias by obtaining a wide variety of participants in their groups. In addition, an effort was made to include a balance of military personnel, families of military personnel and civilians. This was accomplished by partnering with a local community leader, who assisted in recruiting focus group participants. All community members over 17 years old were eligible for inclusion. Focus groups were conducted in each province until thematic saturation was reached for that province.
Separate healthcare provider focus groups were conducted in the same three Zambian provinces, and additional provider focus groups were conducted in Lusaka. We sought to include all types of healthcare providers, from pharmacists and nurses to clinical officers and medical doctors. The providers who participated in Lusaka were gathered from all over the country, so the results for healthcare providers were analysed as a whole. No community focus groups were conducted in Lusaka as healthcare access is better in the capital city and the focus of the study was on groups with the poorest emergency care access.
English is the official language of Zambia, but there are several recognised regional languages. As some community members in rural areas do not speak English, facilitators were selected who were fluent in English and local languages, and focus groups were conducted in the predominant community language. Additional healthcare provider focus groups were conducted in English in Lusaka by the investigator team.
For both cohorts, focus groups were audio recorded; Zambian facilitators immediately translated and transcribed the recordings into English. The translations and transcriptions were checked by another Zambian facilitator for accuracy.
Data analysis
Data were analysed by the investigators with NVivo using the content analysis approach.18 The lead investigator first read each transcript to form general impressions and to look for sections that might have been poorly transcribed. Next, the lead and another investigator developed codes for the data, agreed on a coding strategy, and independently coded each transcript.18 Coding was compared and aggregated, and the lead investigator performed a thematic analysis of the community focus groups to identify exposure to emergencies, desire to provide assistance, barriers to emergency care and ideas for potential interventions. The healthcare worker focus groups were analysed to identify how emergency care is accessed and delivered in their communities, problems identified in the provision of emergency care and ways emergency care could be improved.
Ethical approval was obtained from the University of Cape Town and Johns Hopkins University; additional approval was received from the ZDF and MoH.
Results
We conducted 21 community focus groups with 183 participants, split equally between the three provinces. An additional six were conducted with Zambian healthcare providers; one in each province and three in Lusaka. Healthcare providers represented a mix of pharmacists, nurses, clinical officers and medical doctors.
For the purpose of the focus groups, ‘medical emergency’ refers to any life-threatening condition requiring emergency care, whether obstetric, traumatic or medical in nature. This was explained to participants to differentiate from emergencies such as fire or flooding.
Exposure to medical emergencies
Most community members understood a medical emergency to be a life-threatening medical condition requiring immediate intervention. No one gave an inappropriate or ‘wrong’ answer. When asked if they had personally witnessed or experienced a medical emergency, 69% responded that they had witnessed at least one and 39% had witnessed three or more. Table 1 shows the most common emergencies referenced by community members.
Emergencies experienced by community members
When grouped by categories, medical emergencies (45%) were the most frequently mentioned, followed by traumatic (42%) and obstetric (13%).
In their personal experiences with emergencies, participants referenced private vehicles being used for transport to healthcare facilities most frequently (22%). Bicycles (17%) and taxis (16%) were also commonly referenced, as were walking (12%) and ambulances (8%). The remaining types of transportation were less frequently mentioned, and included carrying the patient, ox carts, wheelbarrows and specific vehicles such as trucks, minibuses and motorcycles.
Assistance and willingness to help
When recounting their personal experiences with emergencies, most community members referenced assistance being provided to the patient at the scene of the illness or injury, most commonly by a family member. Assistance was also frequently provided by a general community member or neighbour, police, coworkers, military personnel and friends.
Most participants (85%) would help someone suffering a medical emergency. Participants reported that they would help because they feel a sense of community with their neighbours, and would want to receive help from others in an emergency. They also frequently said that they would help if they had the necessary training, knowledge or resources. The most common reasons not to help were fear, lack of knowledge about the emergency and how to help, and lack of necessary transportation or equipment.‘But I think that the tendency shows that people are very willing to help. This is one positive thing. But it's educating them to do the right thing, the willingness is there’.
–Provider
‘What makes us help is love. Wherever you are staying, you make a family. If you don't have parents or relatives and you get sick your neighbours will help you’.
–Copperbelt
Community members overwhelmingly felt that they could help during an emergency by providing transport for the patient to the hospital. Another common response was that participants would help by providing some sort of first aid, such as controlling bleeding. Interestingly, several participants commented that one should not provide any first aid without proper training, as there is the potential to do more harm than good. Others felt that they could help by providing medication, traditional remedies, food or simply comfort or advice to the patient.
Barriers to emergency care
The responses of both community members and healthcare providers regarding perceived barriers to receiving emergency care could be grouped in five major themes:
Transportation
Transportation was the most commonly referenced barrier to care by community members (41%). Most often, transportation was not available during an emergency. The distance to travel to reach a healthcare facility was also a major barrier. Other barriers mentioned were the time it takes for transportation to arrive, lack of fuel for vehicles and poor road conditions. Interestingly, community members only perceived money to be a barrier to care when trying to obtain transportation, as emergency services in Zambia (such as they are) are free. Providers concurred that transportation was a major barrier, both from the community to the initial facility and between healthcare facilities.‘Our area is remote and there are no vehicles. The only vehicle which was there had no fuel. The man could not be taken to the hospital due to absence of transport and he died after some time’.
–Central
Healthcare providers
Healthcare providers were referenced as a barrier in 26% of community responses. Participants felt that facility staff had bad attitudes, and thought they should be quicker to provide emergency care. A common concern was that providers rely on queue order instead of prioritising patients based on severity. Healthcare providers also felt that the absence of a prioritisation system prevented critical patients from receiving timely care. Many participants mentioned staff shortages and lack of specific training in emergency care at healthcare facilities.‘Another thing is that in hospital very sick patient are not given priority but just advised to follow the queue’.
–Central
Community knowledge
A lack of community knowledge about medical emergencies and emergency care was another commonly referenced barrier. Community members often said that they did not know what to do when they encountered an emergency, or mentioned providing an intervention that could be harmful for the patient. Providers were concerned that inability to identify conditions requiring emergent care and lack of knowledge of basic stabilisation cause significant delays in the initiation of care.‘People in the communities are dying due to lack of knowledge on what to do when faced with problems/emergencies’.
–Eastern
Referral system
Often, the initial healthcare facility is unable to care for a patient suffering an acute illness or injury, and the patient needs to be transferred to a higher-level facility. During these instances, community members reported that the patient receives no care or stabilisation at the lower-level facility or during transport. Additionally, patients and families are usually responsible for arranging their transportation to the higher-level facility, compounding the time and cost required to reach care.‘He was taken to Kembe then to Malambanyama. They used an ox cart. He was finally taken to the zone where transport was provided to take him to Liteta. He died at Liteta’
–Provider
‘If they need to be referred that is another problem, because most of them do not have ways of getting to the next level. So others, you give them a referral letter, because you cannot escort them they go back home, they don't even go to the next level’.
–Provider
Police
Certain patients, such as assault victims, are required to be seen at the police station prior to receiving healthcare, and both community members and healthcare providers felt that these policies caused significant delays in receiving care. Providers also pointed out that police officers are usually the first, and only, responders present at the scene of an accident, yet they are not trained in first aid and are thus unable to initiate care.‘I almost beat up this nurse who wanted to refer us back to the police because the case we had brought was a police case. We were told to take the injured person to the police then bring them back. I asked her why we can't leave the patient and have the case registered but she refused. I was very upset that is why we don't take our patients to some clinics’.
–Copperbelt
‘If it's an assault case, it's a police case, so normally doctors would not attend to you before the police gives you that form’.
–Provider
Additional barriers to care that did not fit into these five common themes were lack of accessible healthcare facilities, no functional emergency phone number to call for help, lack of necessary equipment at healthcare facilities and no standard national protocols for emergency care preventing coordinated response to mass casualty incidents.‘Speaking from a civilian point of view I will tell you it is a nightmare trying to access ambulance service. To start with the number 991, I don't know if at all it works. The many times I have tried it for various reason, it does not go through’. –Healthcare provider
Community-identified and provider-identified solutions
When asked for suggestions on how to improve access to emergency care, participants contributed many valuable ideas related to community education, improved communication, improved transportation, provision of prehospital care and the creation of a dedicated national emergency care system.
Community education
The most commonly suggested solution by all groups was to create outreach programmes to educate community members about medical emergencies and first aid. This would include teaching community members how to recognise a medical emergency, how to get the patient to necessary care and how to provide first aid. Providers also highlighted the importance of teaching about instances when ambulances are not necessary to avoid burdening a limited resource.
Improved communication
Community members and healthcare providers wanted a reliably accessible and universally known national toll-free emergency number. Providers also wanted improved communication between facilities, so that hospitals would know if they are receiving emergent transfers.
Improved transportation
Community members felt that there should be more ambulances available for transportation. Providers also wanted more ambulances, but specified that they should be equipped with basic equipment that would allow for patient care during transport. Many community members suggested identifying means of transportation in each community that could be used in an emergency.
Provision of prehospital care
Healthcare providers would like to see trained personnel working in the prehospital sector, with the equipment necessary to allow for care provision before patients reach the healthcare facility and during interfacility transports. Providers also felt that police should receive basic training in emergency care so that they would know what to do at the scene of an accident.
Dedicated emergency care system
Overall, participants want to see a dedicated national emergency care system that is accessible to all Zambians. Providers felt that emergency care should be decentralised and provided at all levels of the healthcare facility, not only at the large referral centres. As patients often travel to several healthcare facilities before reaching a referral hospital, provision of emergency care at lower-level facilities and in the prehospital setting would provide patients with earlier access to care. Community members and providers felt that a prioritisation system should be implemented in facilities so that the most emergent cases would be seen first. There was also agreement between community members and providers that the healthcare workforce should be improved by educating providers in emergency care and increasing the number of providers in facilities. Additionally, healthcare providers wanted to see dedicated areas for acutely ill and injured patients in facilities that are equipped with the necessary resources. Several providers also wanted national standard operating procedures to standardise the approach to emergency care at healthcare facilities throughout the country.
Limitations
This study has two limitations that should be considered. Many community focus groups were conducted in the local languages Bemba or Nyanja, and then translated and transcribed into English. The potential for mistranslation exists, as many words in these languages do not directly translate, so facilitators immediately translated and transcribed their recordings. These translations and transcriptions were checked by another Zambian facilitator to ensure accuracy of the English script. The facilitator teams were comprised of Zambian healthcare providers who have worked within the system; however, every effort was made to control for bias by standardising the focus group script and educating facilitators about bias reduction. Another limitation of this study is the inevitable response bias associated with using three different teams for data collection.
Discussion
This study is the first to ask community members for their input on improving their emergency care system, identifying critical interventions by gathering information about need for and barriers to emergency care.
Analysis of the focus group data identified several common themes. Community members 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 attempt some basic first aid.
Community members and healthcare providers identified barriers to emergency care related to the multiple components of an emergency care system: transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols.
As these communities are already assisting one another during emergencies and are willing to help in the future, an ideal opportunity exists to initiate interventions designed to decrease barriers to emergency care at the community level. When asked for ideas that would increase their access, participants identified many practical, perceptive interventions to reduce the barriers they had previously identified. These interventions range from local, community-based programmes to policy changes at the national level. We have gathered community-suggested and provider-suggested recommendations into three key areas as follows:
Create community training courses in emergency awareness and first response.
Many of the benefits of a formal prehospital emergency care system could be realised by teaching community members basic interventions such as establishing and maintaining an airway, controlling external bleeding and immobilising fractures using available resources.4 Community first responder programmes have been shown to be successful in increasing the emergency care knowledge of community members in African countries, and have been identified as the first tier of a prehospital care system by the WHO.19–21
Strengthen the formal prehospital care system by creating a national emergency phone number, increasing emergency transportation options and training ambulance staff and police officers to provide prehospital care.
Specific interventions in the formal prehospital setting could include creating a national emergency phone number, training providers to provide prehospital care on ambulances, increasing the number of ambulances in the country and optimising their distribution, using ambulances to transfer patients to a higher level of care, and implementing a transfer protocol that requires communication between facilities about the patient. Focus should be placed on increasing the availability of emergency transportation, as emergency transportation saves lives.4 ,22 ,23 This does not have to be limited to conventional ambulances; programmes using motorcycle and bicycle ambulances have also been successful.
Create a dedicated national emergency care system, where all healthcare facilities follow triage protocols, have providers trained in emergency care, and include dedicated areas specifically for emergency resuscitation and stabilisation.
Nationally, some of the most important interventions include the creation of triage protocols and provision of training in emergency care for healthcare providers.4 Triage categorises a patient's need for medical care, prioritising treatment for those with life-threatening conditions ahead of those who are stable and safe to wait. Triage systems are designed to maximise the efficient use of resources, particularly in setting where they are limited, while minimising morbidity and mortality of all patients. Training for healthcare providers should be aimed at those working in small clinics and district hospitals that are often the first to receive acutely ill and injured patients, and those working in the emergency intake areas of larger hospitals. As time is critical, having providers trained in emergency care allows patients to get the necessary care more quickly, thereby reducing morbidity and mortality, length of stay and cost.4 ,9
In summary, community members and healthcare providers report the need for a wide range of interventions: local and national, simple and complex. Participants identified what they felt to be necessary interventions at all levels of the healthcare system, beginning with their communities and local healthcare facilities and stretching all the way to national policy. And while some of the proposed solutions require substantial financial investment, the most frequently suggested solutions are the most low cost: prioritising education in first aid for community members and in basic emergency care for healthcare providers, and implementing triage protocols at existing healthcare facilities.
Acknowledgments
The authors would like to thank our collaborators in the Zambian Defence Force and the Zambian Ministry of Health: David Ndhlovu, Geoffrey Sandala, Nelson Lombe, Emmanuel Jonga, Alex Musweu and Esther Sakala, who facilitated the focus group discussions. The authors would also like to thank the American International Health Alliance for their support of this project.
References
Footnotes
Contributors All authors conceived and designed the study. MCB, CC and MT supervised the conduct of the trial and data collection. MCB and CC coded and analysed the data. MCB drafted the manuscript, and all authors contributed substantially to its revision.
Competing interests None declared.
Ethics approval University of Cape Town, Johns Hopkins University.
Provenance and peer review Not commissioned; externally peer reviewed.