Prehospital barriers for rural New Zealand parents in paediatric appendicitis: a qualitative analysis

Abstract

Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist. We conducted individual, semi-structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019-January 2020. Utilising grounded theory methodology, we created an exploratory framework. Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to 'watch and wait' due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community-based health advice to mitigate these barriers, leading to earlier hospital presentation. Prehospital delay in rural families occurred most frequently due to an extended decision-making phase where families evaluated the costs and benefits of accessing hospital-level care. The utilisation of informal community expertise and whānau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Māori families.