Social Determinants of Seeking and Reaching Injury Care in South Africa: A Community-Based Qualitative Study.

Background: Timely access to quality injury care saves lives and prevents disabilities. The impact of social determinants of health on the high injury prevalence in South Africa is well documented, however, evidence of their role in accessing injury care is lacking. This study explored the social determinants of seeking and reaching injury care in South Africa. Methods: This was a qualitative study involving rural and urban patients, community members, and healthcare providers in Western Cape, South Africa. Data were obtained through semi-structured interviews and focus group discussions using an interview guide informed by the four-delays framework. Inductive and deductive approaches were used for thematic analysis. Results: A total of 20 individual interviews and 5 focus group discussions were conducted. There were 28 males (individual interviews: 13; focus groups: 15) and 22 females (individual interviews: 7; focus groups: 15), and their mean age was 41 (standard deviation ±15) years. Barriers to seeking and reaching injury care cut across five social determinants of health domains: healthcare access and quality; neighbourhood and environment; social and community context; education; and economic stability. The most prominent social determinants of seeking and reaching injury care were related to healthcare access and quality, including perceived poor healthcare quality, poor attitude of healthcare workers, long waiting time, and ambulance delays. However, there was a strong interconnection between these and neighbourhood and environmental determinants such as safety concerns, high crime rates, gangsterism, lack of public transportation, and social and community factors (presence/absence of social support and alcohol use). Barriers related to education and economic stability were less prevalent. Conclusion: We found a substantial role of neighbourhood, social, and community factors in seeking and reaching injury care. Therefore, efforts aimed at improving access to injury care and outcomes must go beyond addressing healthcare factors to include other social determinants and should involve collaborations with multiple sectors, including the community, the police, the transport department, and alcohol regulation agencies.

The impact of data feedback on continuous quality improvement projects in Rwanda: A mixed methods analysis.

BACKGROUND: Injuries are a leading cause of death and disability globally. Over 90% of injury-related mortality happens in low- and middle- income countries (LMICs). Rwanda's pre-hospital emergency system - Service d'Aide Medicale Urgente (SAMU) - and their partners created an electronic pre-hospital registry and Continuous Quality Improvement (CQI) project in 2014. The CQI showed progress in quality of care, sparking interest in factors enabling the project's success. Healthcare workers (HCW) are critical pieces of this success, yet we found a void of information linking pre-hospital HCW motivation to CQI programs like SAMU's. METHODS: Our mixed methods approach included a 40-question survey using questions regarding HCW motivation. We scored the surveys to compare SAMU staff motivation with other HCWs in LMICs, and used a Likert scale to elicit agreement or disagreement. A semi-structured interview based on employee motivation theory qualitatively explored SAMU staff motivation using constructivist grounded theory. To find interview themes, two researchers independently performed line-by-line analysis. RESULTS: SAMU staff received 5-21% higher motivation scores relative to other cohorts of HCWs in LMICs. Questions showing disagreement (five) asked about reprimand, damaged social standing, and ease of using the CQI technology. Three questions did not show consensus. Questions showing agreement (23) and strong agreement (nine) asked about organizational commitment, impact, and research improving patient care. Major themes were: improvements in quality of care, changes in job expectations, views on research, and positive experiences with data feedback. CONCLUSIONS: The CQI project provides constant feedback vital to building and sustaining successful health systems. It encourages communication, collaboration, and personal investment, which increase organizational commitment. Continuous feedback provides opportunities for personal and professional development by uncovering gaps in knowledge, patient care, and technological understanding. Complete, personalized data input encouraged by the CQI improves resource allocation, building robust health systems that improve HCW agency and motivation.