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
BMJ Open, vol. 14, pp. e081652
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.
Authors 7
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Affiliation as printed
Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, USA
Michigan State University, East Lansing, Michigan, USA
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Leiden University Medical Center · London School of Hygiene & Tropical Medicine · Malawi Epidemiology and Intervention Research Unit
Affiliation as printed
Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
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Malawi Epidemiology and Intervention Research Unit
Affiliation as printed
Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
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National Health Service · University of the Witwatersrand · University of Aberdeen · Stellenbosch University · NHS Grampian · Umeå University · Medical Research Council
Affiliation as printed
Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
Public Health, National Health Service (NHS) Grampian, Grampian, Scotland
Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences,
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health,
School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
University of the Witwatersrand, Johannesburg, South Africa
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Royal Centre for Defence Medicine
Affiliation as printed
Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Affiliation as printed
School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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University of the Witwatersrand · Stellenbosch University · University of Birmingham · Medical Research Council
Affiliation as printed
Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
Institute of Applied Health Research, University of Birmingham, Birmingham, UK
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health,
University of the Witwatersrand, Johannesburg, South Africa
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