Dataset Information

Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study.

ABSTRACT:

Objectives

The Three Delays Model has been commonly used to understand and prevent maternal mortality but has not been systematically applied to emergency medical conditions more generally. The objective of this study was to identify delays in emergency medical care seeking and delivery in rural Bangladesh and factors contributing to these delays by using the Three Delays Model as a framework.

Design

A qualitative approach was used. Data were collected through focus group discussions and in-depth interviews using semistructured guides. Two analysts jointly developed a codebook iteratively and conducted a thematic analysis to triangulate results.

Setting

Six unions in Raiganj subdistrict of Bangladesh.

Participants

Eight focus group discussions with community members (n=59) and eight in-depth interviews with healthcare providers.

Results

Delays in the decision to seek care and timely receipt of care on reaching a health facility were most prominent. The main factors influencing care-seeking decisions included ability to recognise symptoms and decision-making power. Staff and resource shortages and lack of training contributed to delays in receiving care. Delay in reaching care was not perceived as a salient barrier. Both community members and healthcare providers expressed interest in receiving training to improve management of emergency conditions.

Conclusions

The Three Delays Model is a practical framework that can be useful for understanding barriers to emergency care and developing more tailored interventions. In rural Bangladesh, training community members and healthcare providers to recognise symptoms and manage acute conditions can reduce delays in care seeking and receiving adequate care at health facilities.

SUBMITTER: Shah B

PROVIDER: S-EPMC7759951 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Publications

Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study.

Shah Bansari B Krishnan Nandita N Kodish Stephen R SR Yenokyan Gayane G Fatema Kaniz K Burhan Uddin Kazi K Rahman A K M Fazlur AKMF Razzak Junaid J

BMJ open 20201223 12

<h4>Objectives</h4>The Three Delays Model has been commonly used to understand and prevent maternal mortality but has not been systematically applied to emergency medical conditions more generally. The objective of this study was to identify delays in emergency medical care seeking and delivery in rural Bangladesh and factors contributing to these delays by using the Three Delays Model as a framework.<h4>Design</h4>A qualitative approach was used. Data were collected through focus group discussi ...[more]

PMID: 33361169

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Project description:BackgroundIn the past fifteen years, Afghanistan has made substantial progress in extending primary health care. However, coverage of essential health interventions proven to improve maternal and neonatal health outcomes, particularly skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. This cross-sectional quantitative and qualitative study assessed barriers associated with care-seeking for institutional delivery among rural Afghan women in three provinces.MethodsThe study was conducted from November to December 2016 in 12 districts across three provinces - Badghis, Bamyan, and Kandahar - which are predominately rural. Districts were used as the primary sampling unit with district-level sample sizes reflecting the ratio of that district's population to provincial population. Villages within these districts, the secondary sampling units, were randomly selected. A household survey was used to collect data on: demographics, socio-economic status, childbearing history, health transport and service costs, maternal health seeking behavior and barriers to service uptake. Data on barriers to facility delivery were compared across provinces using chi square tests.ResultsOf the 2479 women of child bearing age interviewed, one-third were from each province (33% n = 813 Badghis, 34% n = 840 Bamyan, 33% n = 824 Kandahar). Among those respondents who had delivered none of their children in a health center, money to pay for services appeared to be most important barrier to accessing institutional delivery (56%, n = 558). No transportation available was the second most widely cited reason (37%, n = 368), followed by family restrictions (n = 30%, n = 302). Respondents in Badghis reported the highest levels of barriers compared to the other two provinces. Respondents in Badghis were more likely to report familial or cultural constraints as the most important barrier to institutional delivery (43%) compared to Bamyan (2%) and Kandahar (12%) (p < 0.001).ConclusionsDespite the socio-demographic and geographic diversity of the three provinces under study, the top barriers to institutional delivery reported in all three areas are consistent with available evidence, namely, that distance, transport cost and transport availability are the main factors limiting institutional delivery. Proven and promising approaches to overcome these barriers to institutional delivery in Afghanistan should be explored and studied.

Project description:BackgroundCaesarean section is a lifesaving surgical intervention for women and their newborns, though overutilization is a public health concern. The caesarean rate in Bangladesh is approximately 23% overall, and in private facilities it is over 70%. It is essential to know both the supply side (obstetricians) and demand side (parturient women) views on caesarean birth in order to formulate specific interventions to address the escalating rate of caesareans.MethodsThis qualitative study took place in Matlab, a rural sub-district in Bangladesh. We interviewed women attending their 3rd antenatal visit, those with recent caesareans, and obstetricians from both public and private health facilities. In total there were twenty in-depth interviews and four focus group discussions. Study participants were asked about their preferences on birthing mode and knowledge of the caesarean section process. Thematic data analysis was done following a deductive approach.ResultsWomen from this rural community had a strong preference for normal vaginal birth. However, they were willing to accept the attending health care provider's decision for caesarean birth. Antenatal care sessions did not provide information on the medical indications for caesarean section. Furthermore, some women had the misconception that episiotomy itself is a 'small caesarean.' Primary health care providers and clinic agents (brokers) had a strong influence on women's decision to choose a health facility for giving birth. However, obstetricians, having a preference for caesarean section, were receiving more patients from these brokers which may be an important reason for the high rate of clinically non-indicated caesareans at private hospitals in Bangladesh. Improper labour monitoring and inadequate staffing at health facilities were additional influences on the preference for caesarean section. However, critical knowledge gaps were also observed among study obstetricians, particularly with regards to the indications for and timing of elective caesarean sections.ConclusionThere is a need to educate women about the advantages and disadvantages of different birthing modes to ensure their active participation in the decision making process. Strong policy regulations are needed to ensure legitimate decision making by obstetricians regarding mode of birthing.

Project description:BackgroundEarly diagnosis of tuberculosis (TB) and involvement of the public-private partnership are critical to eradicate TB. Patients need to receive proper treatment through the National Tuberculosis Control Programme (NTP). This study describes various predictors for health seeking behaviour of TB patients and health system delay made by the different health care providers.MethodsA cross-sectional study was conducted in a public health facility of a rural area in Bangladesh. Newly diagnosed smear positive pulmonary TB (PTB) patients who were ≥ 15 years of age were sequentially enrolled in this study. The socio-demographic characteristics and proportion of health care utilization by the patients, and health system delay made by the health care providers were calculated. Multivariate analysis was conducted to determine the independent association of the risk factors with the time to seek medical care.ResultsTwo hundred and eighty patients were enrolled in this study. Among them, 73.6% were male and 26.4% were female. A hundred percent of patients primarily sought treatment for their cough, 170 (60.7%) first consulted a non-qualified practitioner while 110 patients (39.3%) first consulted with qualified practitioners about their symptoms. Pharmacy contact was the highest (27.9%) among the non-qualified practitioners, and 58.9% non-qualified practitioners prescribed treatment without any laboratory investigation. The average health system delay was 68.5 days. Multiple logistic regressions revealed a significant difference between uneducated and educated patients (OR 2.33; CI 1.39-3.92), and qualified and non-qualified practitioners (OR 2.34; CI 1.38-3.96) to be independent predictors of health system delay.ConclusionsCompared to men, fewer women sought TB treatment. Uneducated patients and questionably qualified practitioners made for a longer delay in detecting TB. Increasing public health awareness and improving health seeking behavior of females and uneducated patients, and greater participation of the qualified practitioners in the NTP are highly recommended.

Project description:IntroductionDelays due to long distances to health facilities, poor road infrastructure, and lack of affordable transport options contribute to the burden of maternal deaths in Mozambique. This study aimed to assess the implementation and uptake of an innovative community-based transport program to improve access to emergency obstetric care in southern Mozambique.MethodsFrom April 2016 to February 2017, a community transport strategy was implemented as part of the Community Level Interventions for Pre-eclampsia Trial. The study aimed to reduce maternal and perinatal mortality and morbidity by 20% in intervention clusters in Maputo and Gaza Provinces, Mozambique, by involving community health workers in the identification and referral of pregnant and puerperal women at risk. Based on a community-based participatory needs assessment, the transport program was implemented with the trial. Demographics, conditions requiring transportation, means of transport used, route, and outcomes were collected during implementation. Data were entered into a REDCap database.ResultsFifty-seven neighborhoods contributed to the needs assessment; of those, 13 (23%) implemented the transport program. Neighborhoods were selected based on their expression of interest and ability to contribute financially to the program (US$0.33 per family per month). In each selected neighborhood, a community management committee was created, training in small-scale financial management was conducted, and monitoring tools were provided. Twenty people from 9 neighborhoods benefited from the transport program, 70% were pregnant and postpartum women.ConclusionThese results demonstrate that it was feasible to implement a community-based transport program with no external input of vehicles, fuel, personnel, and maintenance. However, high cost and a lack of acceptable transport options in some communities continue to impede access to obstetric health care services and the ability for timely follow-up. When strengthening capacities of community health workers to promptly assist and refer emergency cases, it is crucial to encourage local transport programs and transportation infrastructure among minimally resourced communities to support access and engagement with health systems.

Project description:BackgroundWhile women in low- and middle-income countries face a range of barriers to accessing care for hypertensive disorders of pregnancy, there is little understanding of the pathways taken to overcome these constraints and reach the services they need. This study explores the perspectives of women and communities on the influences that impact care-seeking decisions and pathways to health services.MethodsTo understand individual perspectives, we conducted 22 in-depth interviews (IDIs) with pre-eclampsia and eclampsia survivors (PE/E) in a tertiary hospital, where they received care after initiating PE/E services in different parts of the country. In four districts, we conducted one male and one female focus group discussion (FGD) to unearth care-seeking pathways and explore normative perspectives and the range of internal and external influences. Careful thematic analysis using Atlas-ti was applied.ResultsPrevailing views of women and communities across settings in Bangladesh indicate varied pathways to care throughout their pregnancy, during childbirth, and in the postnatal period influenced by internal and external factors at the individual, familial, social, and health systems levels. Internal influences draw on women's own awareness of hypertension complications and options, and their ability to decide to seek care. External factors include social influences like family and community norms, culturally-accepted alternatives, and community perceptions of the health system's capacity to provide quality care. The interaction of these factors often delay care seeking and can lead to complex pathways to care.ConclusionWomen's individual pathways to care were diverse, despite the homogenous community perceptions of the influences on women's care-seeking behaviors. This finding supports the need for improving quality of care in primary healthcare facilities and strengthening gender equity and community-based promotion activities through targeted policy and programming.

Project description:ObjectivesThis study aimed to better understand reasons why children in South Africa die at home, including caregivers' care-seeking experiences, decision-making, choice of treatment provider and barriers to accessing care during a child's final illness.DesignThis qualitative study included semi-structured in-depth interviews and focus group discussions with caregivers of children who died below the age of 5 years. Data were thematically analysed, and key findings compared with the Pathways to Survival Framework-a model frequently used in the study of child mortality. An adapted model was developed.SettingTwo rural health and demographic surveillance system (HDSS) sites in South Africa-the Agincourt HDSS and the Africa Health Research Institute.ParticipantsThirty-eight caregivers of deceased children (29 participated in in-depth interviews and 9 were participants in two focus group discussions). Caregivers were purposively sampled to ensure maximum variation across place of death, child age at death, household socioeconomic status, maternal migration status and maternal HIV status.FindingsAlthough caregivers faced barriers in providing care to children (including insufficient knowledge and poor transport), almost all did seek care from the formal health system. Negative experiences in health facilities did not deter care-seeking, but most respondents still received poor quality care and were not given adequate safety-netting advice. Traditional healers were only consulted as a last resort when other approaches had failed.ConclusionBarriers to accessing healthcare disrupt the workings of previously accepted care-seeking models. The adapted model presented in this paper more realistically reflects care-seeking experiences and decision-making during severe childhood illness in rural South Africa and helps explain both the persistence of home deaths despite seeking healthcare, and the impact of a child's death on care-seeking in future childhood illness. This model can be used as the basis for developing interventions to reduce under-5 mortality.

Dataset Information

Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study.

Objectives

Design

Setting

Participants

Results

Conclusions

Publications

Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study.

Similar Datasets

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