부산대학교 도서관

Background: Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings. Methods and findings: To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers—25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework. Conclusions: By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy. Using a mixed-methods approach, John Whitaker and colleagues examine barriers to seeking, reaching, or receiving care in the injury care health system in Karonga, Northern Malawi. Author summary: Why was this study done?: Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While evidence suggests that many health systems underperform in treating injured patients in LMICs, most assessments have not considered all elements of the healthcare system for injured people. Innovative mixed methods approaches to holistic health system assessment including community and facility perspectives are therefore needed. What did the researchers do and find?: To examine the injury care health system in Karonga, Northern Malawi, we integrated the findings from 9 different methods: (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker surveys; (7) facility assessment surveys; (8) clinical vignettes for care quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. We graded the strength of evidence each method provided as to whether a given barrier was important in inhibiting access to timely quality injury care. We found 26 barriers evidenced by at least 3 of the 9 methods with the barriers "cost," "transport," and "physical resources" having the strongest evidence that they were important barriers delaying seeking, reaching, and receiving care, respectively. What do these findings mean?: By comparing the findings from the perspectives of 9 different methods, we were able to gain an in-depth understanding of the health system for trauma care. This approach can allows researchers and planners to know the barriers consistently shown to be important and prioritise health service development and policy interventions accordingly. This study, to our knowledge, represents a novel and innovative approach in terms of both the number and types of methods mixed, serving as an example other researchers could use in similar contexts. The way we graded evidence strength for comparison across methods was somewhat subjective and other researchers may have made different judgements. [ABSTRACT FROM AUTHOR]