Delay In Seeking Care Research Articles

Health services gaps experienced by non-standard workers in Ontario, Canada: Policy implications

Abstract Background While the Canadian universal health system provides access to basic services, key health benefits are employer dependent. Given that non-standard workers (NSWs) only rarely have access to such benefits they have increased vulnerability to the many insecurities derived from their precarious employment, as clearly seen during the pandemic. The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern. This study summarizes several health services gaps experienced by NSWs and discusses policy implications and possible solutions. Methods From January to July 2021, we conducted semi-structured interviews with a purposive sample of 40 NSWs in Ontario, Canada, part of a larger mixed-methods six-country study, including three European countries. The target population consisted of workers aged 25 to 55 who, at the time of the survey, were in non-standard employment or lost their job due to the COVID-19 pandemic. Results Our findings highlight complex physical and mental health problems and an overall high burden of disease facing NSWs during the pandemic as linked to a combination of constant stress and worry arising from their employment insecurity, the limited and inconsistent income available to cover their basic needs, and the inadequate and unsafe working conditions they are afraid to challenge. Despite their increased health needs, given that specialized health services are not available to them for free they face financial barriers in accessing much needed health services that could help improve their health status and as a result, delay seeking care or avoid it altogether. Conclusions Sustainable multi sectorial policy solutions are needed including the adoption of relevant labour market legislation and increases in social and health expenditures along with re-adjustments in the ways in which health services are delivered. Key messages • During the pandemic non-standard workers in Ontario, Canada experienced complex health problems and, despite increased health needs, encountered barriers in accessing specialized health services. • The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern.

Impact of COVID-19 on hospitalisation for diverse conditions in European countries

Abstract Background The COVID-19 pandemic has had an unprecedented impact on Europe. Health systems came under strain, with non-urgent treatments postponed and resources reserved for treatment of COVID-19 patients. Delayed care seeking has been reported, for fear of infection with SARS-CoV2. Yet, the scale of this impact remains under researched. This study aims to compare indirect effects of the pandemic in a European cross-country study aiming to highlight the potential of Population Health Information Research Infrastructures (www.phiri.eu). Methods Focusing on (i) major vascular events (MVE) and (ii) elective surgery for joint replacements (ESJR) as well as (iii) serious trauma this study analyses individual level hospital data in a standardised harmonised data model. We compared pre-pandemic incidence rates (2018-2019) with rates for 2020 and 2021. Analyses are systematically contrasted with SARS CoV2 incidence rates, and policy measures taken based on the OxCGRT index. Results A drop in hospital discharge rates was observed during the pandemic in all countries but differing by condition and month. Socio-economic differences also varied by condition. Our evidence suggests that periods of more severe policy measures also correlated with more dramatic drops in regular hospital activities. Conclusions Our findings provide new insights on the dramatic level of de-prioritisation of essential services faced by non-COVID-19 patients in Europe. From a public health perspective, hospital escalation plans should be developed early on to avoid negative mid and long-term health and financial consequences of indirect effects. The study demonstrates the tremendous potential in exploiting health information systems in a systematic way across countries and the value of the PHIRI system. Further research should investigate policy trade-offs involved in severe lockdown measures during a pandemic and variations in health service resilience for future pandemic preparedness.

Do as I Say, Not as I Do: Resident Physicians’ Approach to Seeking Care During Times of Acute Physical Illness

INTRODUCTION: Surgeons must be healthy to perform surgery safely. Surgical residents may not seek appropriate care when acutely physically ill due to demands and workplace culture. This study aimed to understand delays in seeking care and use of informal care among surgical residents. METHODS: Cross-sectional multi-institutional survey of residents from nine geographically diverse US general surgery residencies that explored the topics of healthcare for physical illness, delay in care, and informal care (self-diagnosing or diagnosed/treated by colleagues) (Figure). Quantitative data were evaluated with summary statistics.FigureRESULTS: The response rate was 50% (232/460). Sixty-three percent (147/232) reported having delayed care for a physical condition since starting residency. The most common reason for delaying care was not wanting to create more work for colleagues, which was reported by 72% (106/147). The most common consequence of delaying care was declining work quality in 27% (39/147), while 18% (26/147) reported having an emergency procedure that could have been avoided. Overall, 62% (144/232) reported having self-diagnosed/self-treated a physical illness while 60% (140/232) reported asking for informal care from a colleague. Of the informal care accessed, 44% (63/144) reported self-prescribing prescription medications while 44% (61/144) asked for a colleague to do so. CONCLUSION: Most surgical residents have delayed seeking care for an acute physical illness during residency. This negatively impacts residents’ health and work quality and is attributed to workload and workplace culture. Not surprisingly, residents access informal care frequently. Structural and cultural change are needed to ensure the physical well-being of surgical residents.

Language Disparity Predicts Poor Patient-Reported Outcomes and Follow-Up in Microsurgical Breast Reconstruction

INTRODUCTION: Limited English proficiency (LEP) has been associated with lower patient satisfaction, worse outcomes, and delay in seeking care. No study to date has examined LEP in plastic surgery and reconstructive microsurgery. METHODS: A review of all patients with abdominal-based microsurgical breast reconstruction at our institution between 2009 and 2019 was performed. Variables collected include patient demographics, preferred language, interpreter usage, postoperative clinic/ED visits, self-reported outcomes (Breast-Q), and postoperative complication. Statistical analysis was conducted using Pearson’s chi-square test, 2-tailed t-tests, odds ratio analysis, and multivariable regression modeling. RESULTS: In total, 405 patients were included, with 22.22% of patients identifying as LEP and 41.4% identifying as Hispanic; 75% of LEP patients used interpreter services. A 2-year, longitudinal analysis of patient-reported outcomes revealed that LEP-speaking patients reported significantly lower physical well-being scores than English-speaking patients. The chest physical well-being scores were 13.6 (95% CI 6.9–20.2) units lower, and the abdomen physical well-being scores were 19.6 (95% CI 11.7–27.6) units lower. Multivariable regression models demonstrated that LEP was significantly associated with 0.87 days longer length of stay (p = 0.006) and 1.58 fewer postoperative clinic visits (p = 0.041). Interestingly, within LEP cohort, interpreter use was associated with 1.89 more postoperative clinic visits when compared with those who did not use an interpreter (p = 0.027). There were no significant differences in emergency room visits or complication between proficient and LEP speakers. CONCLUSION: Our findings suggest that language disparity exists within microsurgical breast reconstruction and underscore the importance of effective, language-conscious communication.

Maternal Referral Delays and a Culture of Downstream Blaming Among Healthcare Providers: Causes and Solutions.

Patient referral management is an integral part of clinical practice. However, in low-resource settings, referrals are often delayed. The World Health Organization categorizes three types of referral delays; delay in seeking care, in reaching care and in receiving care. Using two case studies of maternal referrals (from a low-resource state in India), this article shows how a culture of downstream blaming permeates referral practice in India. With no referral guidelines to follow, providers in higher-facilities evaluate the clinical decision-making of their peers in lower-facilities based on patient outcome, not on objective measures. The fear of punitive action for an unfavorable maternal outcome is a larger driving factor than patient safety. The article argues for the need to formulate an ecosystem where patient responsibility is shared across the health system. In conclusion, it discusses possible solutions which can bridge communication and information gap between referring facilities.

Six Diagnoses of Separation: Impact of COVID-19 on Pediatric Emergency Department Visits: A Multicenter Study

BackgroundCoronavirus disease 2019 (COVID-19) arrived in the New York metropolitan area in early March 2020. Recommendations were made to self-quarantine within households and limit outside visits, including those to clinics and hospitals, to limit the spread of the virus. This resulted in a decrease in pediatric emergency department (ED) visits. However, it is unclear how this affected visits for some common diagnoses such as anxiety, appendicitis, asthma, headaches, seizures, and urinary tract infection (UTI). These diagnoses were chosen a priori, as they were felt to represent visits to the ED, for which the diagnoses would likely not be altered based on COVID exposure or quarantine due to their acute nature. ObjectivesOur goal was to investigate the effect of COVID-19 on common pediatric diagnoses seen in the pediatric ED using a large multihospital database. MethodsWe conducted a retrospective cohort study of consecutive pediatric patients (age ≤ 21 years) between March 1 and November 30 in 2019 and 2020 in 28 hospital EDs within 150 miles of New York City. We compared the change in the number of visits from 2019 to 2020 for the following diagnoses: anxiety, appendicitis, asthma, headache, seizures, and UTI. ResultsOur database contained 346,230 total pediatric visits. From 2019 to 2020, total visits decreased by 61%. Decreases for specific diagnoses were 75% for asthma, 64% for headaches, 47% for UTI, 32% for anxiety, 28% for seizures, and 18% for appendicitis (p value for each comparison < 0.0001). ConclusionsWe found a marked decrease in ED visits for six common pediatric diagnoses after COVID-19 arrived in our area. We suspect that this decrease was due to recommendations to quarantine and fear of contracting the virus. Further studies on other diagnoses and potential complications due to the delay in seeking care are needed.

Health Care Use Prior to Diabetes Diagnosis in Children Before and During COVID.

During COVID-19, healthcare systems reorganized with less ambulatory care and a shift to virtual care (1). There was an increase in diabetic ketoacidosis (DKA), a preventable, life-threatening condition, at diabetes onset in children during COVID-19 (2). DKA at diabetes onset has been attributed to delays in seeking care, missed diagnosis or delays in referral following a primary healthcare contact (3). Reasons for the recent increase in DKA may relate to hesitancy to seek care, providers failing to recognize diabetes symptoms due to cognitive bias focusing on COVID-19, or limitations of virtual care. To explore these potential mechanisms, we compared in-person and virtual primary care and emergency department (ED) visits in children four weeks prior to diagnosis, before and during COVID-19. If increased DKA rates during COVID-19 were due to more missed diagnoses, possibly related to virtual visits, children with DKA would be more likely to have visits during vs. pre-COVID-19. If families were hesitant to seek or unable to access care during COVID-19, then among those with no visits, there would be a higher proportion with DKA.

Mothers’ Lives Matter: Reaffirming Commitments from the Past to Strengthen the Future

The death of a woman from pregnancy or childbirth is one death too many. The death of a mother immediately cuts into half her newborn child’s chances of survival.Maternal death is of great concern worldwide, with eight to nine women dying daily, succumbing to various medical and compounding reasons. Approximately 75% of maternal mortalities during or following birth are due to severe bleeding, infections, pre-eclampsia and eclampsia, complications from delivery, and unsafe abortions.1&#x0D; Delays in seeking, reaching, and receiving adequate maternity or obstetric services contribute to maternal mortality.2 The last five decades saw tremendous efforts at the national and international level to improve maternal and neonatal care and mitigate maternal and child mortalities. From the 1978 Alma Ata Declaration on Primary Health Care to the Millennium and Sustainable Development Goals at the turn of the century, global commitment has been continuous.The Department of Health launched the National Safe Motherhood Program (NSMP) which envisions Filipino women having full access to health services for safe pregnancy and delivery by providing technical assistance to and collaborating with Local Government Units (LGUs) in the provision of maternity and newborn services.3&#x0D; The Maternal Newborn and Child Health and Nutrition (MNCHN) strategy framework is a corollary to the NSMP and also aims to reduce the maternal and neonatal mortality rates. MNCHN integrates services and programs for maternal health, family planning, and the prevention of sexually transmitted infections by proposing a continuum of care from pregnancy to delivery and ensures care for children and adolescents.&#x0D; Basic Emergency Obstetric and Newborn Care, or BEmONC, is one of the service packages of the MNCHN strategy that capacitates health care workers at the primary health care level to perform emergency obstetric and newborn resuscitation functions and refer to more equipped facilities for definitive management of obstetric emergencies. Rural health units (RHUs), district hospitals, and private lying-in clinics all over the country were capacitated as BEmONC-provider facilities.4 &#x0D; These facilities were particularly needed in rural areas to reduce the delays in pregnant women reaching and receiving adequate obstetric care. Delays in seeking care may be attributed to women’s beliefs and perceptions of the availability and adequacy of maternityservices in their communities. Articles in this issue give voice to pregnant women, their experiences, and their apprehensions on accessing care in various contexts, including during the COVID-19 pandemic. Also expressed in this issue are the perspectives of health workers on providing much-needed maternal health care.&#x0D; This collection provides but a brief snapshot of the compendium of challenges faced by Filipino women and children, the two great vulnerable groups in our society today. This issue pushes an essential dialogue forward: the importance we give to the lives of women in general, and mothers and children in particular.&#x0D; This is a continuing dialogue that everyone should hear and partake of.&#x0D; Ma. Carmeriza B. Buñing, MD, FPOGS Assistant Professor IADepartment of Anatomy, College of Medicine, UERMMMCI&#x0D; &#x0D; REFERENCES1. World Health Organization. Maternal Mortality [Internet]. 2019 [cited 2022 Aug 30]. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.2. Thaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context. Soc Sci Med. 1994; 38(8):1091-1110. https://doi.org/10.1016/0277-9536(94)90226-7 3. Department of Health. National Safe Motherhood Program [Internet]. 2018 [cited 2022 Aug 30]. Available from: https://www.doh.gov.ph/national-safe-motherhood-program. 4. Department of Health. Implementing Health Reforms towards Rapid Reduction in Maternal and Neonatal Mortality: Manual of Operations [Internet]. 2009 [cited 2022 Aug 30]. Available from: https://www.doh.gov.ph/sites/default/files/publications/maternalneonatal.compressed.pdf.

Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers.

Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers. The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk. Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region. While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.

Oral Complaint Visits to the Pediatric Emergency Department During the COVID-19 Pandemic.

Objective: We aimed to describe differences in orofacial complaints presenting to a pediatric emergency department (PED) during the COVID-19 pandemic as compared to those presenting prior to the pandemic.Study design: A retrospective review was conducted in the PED from March 16, 2020, to August 16, 2020, and compared with the prior year.Results: Despite a 41% reduction in total PED visits, oral visits as a percentage of PED volume increased (3% vs 2%) P < 0.01) during the pandemic. More children with dental complaints required intervention during the pandemic (48% vs 30%, P < 0.001) including extractions and splinting (15% vs 1%, P < 0.001). Compared with pre-pandemic, proportion of tooth infections increased (68% vs 40%, P < 0.001), while oral ulcers decreased (19% vs 47%, P < 0.001).Conclusion: Pediatric emergency department presentation decreased during the pandemic, but patients requiring interventions increased. This may reflect hesitation in seeking treatment, outpatient facility closures, and increased acuity at the time of PED presentation due to delays in seeking care.

Neuroimaging in Pediatric Stroke

Pediatric stroke is unfortunately not a rare condition. It is associated with severe disability and mortality because of the complexity of potential clinical manifestations, and the resulting delay in seeking care and in diagnosis. Neuroimaging plays an important role in the multidisciplinary response for pediatric stroke patients. The rapid development of adult endovascular thrombectomy has created a new momentum in health professionals caring for pediatric stroke patients. Neuroimaging is critical to make decisions of identifying appropriate candidates for thrombectomy. This review article will review current neuroimaging techniques, imaging work-up strategies and special considerations in pediatric stroke. For resources limited areas, recommendation of substitute imaging approaches will be provided. Finally, promising new techniques and hypothesis-driven research protocols will be discussed.

Reasons for Delay in Seeking Treatment for Dental Caries in Tanzania

IntroductionThe delay in seeking dental treatment is a universal health problem, with a reported prevalence as high as 98%. It is a critical feature not only in planning management but also in the final treatment outcome. AimThis study aimed to determine the reasons for the delay in seeking treatment for dental caries amongst patients attending public dental clinics in Dar es Salaam, Tanzania. MethodologyThis was a cross-sectional study carried out in 5 public hospitals in Dar es Salaam, Tanzania. It included 315 adult patients who had dental caries. Data were collected using a questionnaire that included questions regarding reasons for the delay in seeking care for dental caries. Data were analysed using the SPSS computer software version 26. A one-way analysis of variance was used to assess the association between variables, and the significance level was set at P < .05. ResultsA majority (n = 244, 77.5%) of the participants delayed seeking dental care upon noting a problem in their teeth. However, the association between the sociodemographic characteristics of the participants and delay in seeking dental care was statistically insignificant (P > .05). The most common reason given by the participants who delayed seeking dental care for their decayed teeth included self-negligence (n = 184, 75.4%), the practice of self-medication (n = 164, 67.2%), and ignorance (n = 110, 45.1%). ConclusionsThe majority of patients experiencing dental caries seek dental care very late. Delay in seeking dental care is not dependent on sociodemographic characteristics of individuals. Self-negligence, the practice of self‑medication, and ignorance are the major reasons for the delay.

Persistent inequities in access to and continuity of gynecologic oncology care during the COVID-19 pandemic (052)

Objectives: Access to health care was jeopardized during the COVID-19 pandemic due to the unforeseen increase in unmet social needs and financial strain. The pandemic exacerbated social determinants of health that impact systemic health disparities. Furthermore, fear of COVID-19 may have prompted patients with cancer symptoms to delay seeking care. We aimed to assess the impact of race, ethnicity, and insurance status on access to and continuity of gynecologic oncology (GO) care before and during the COVID-19 pandemic.Methods: This was a retrospective cohort study of women newly referred to an NCI-designated cancer center for evaluation by GO during the five months prior to COVID-19 (Oct 2019-Feb 2020) compared to the first five months of the pandemic (Apr 2020-Aug 2020). Descriptive statistics were used to report proportions of new referrals based on race, ethnicity, and insurance, and comparisons between time periods were made using Chi-square tests. Among confirmed cancer patients, time to initial GO visit as well as treatment initiation (time from GO evaluation to treatment) were compared between groups using the student’s t-test.Results: Among 884 new referrals, the mean age was 56.5 years, and 416 (47%) had confirmed gynecologic cancer. The majority were White (81.0%), non-Hispanic (96.5%), and privately insured (52.5%). Overall, new referrals decreased by 32% between the two time periods (526 pre-COVID-19 vs 358 during COVID-19) with no differences by race, ethnicity, or insurance status. Among cancer patients, referrals decreased by 18%, and disproportionately affected under-represented racial and ethnic groups (Black, Asian, Hispanic) (22.0% pre-COVID vs 13.6% during the pandemic, p=0.03), while the proportion of Medicaid patients remained stable (12.9% vs 12.5%). During the ten-month study period, the mean time from referral to GO evaluation was significantly longer for Black patients compared to White patients (17.9 days vs 13.6 days, p<0.01), and those with Medicaid compared to patients with private insurance (17.3 days vs 13.2 days, p=0.03). However, cancer treatment initiation differed by race, ethnicity, and insurance. During the five months preceding COVID-19, delays in treatment initiation were significantly longer for Black compared to White patients (43.5 vs 31.6 days, p=0.001), and those with Medicaid than private insurance (44.0 vs 31.1 days, p<0.01). These disparities were not observed during the first five months of the pandemic.Conclusions: These findings demonstrate that social determinants of health (race, ethnicity, and insurance status) influence how quickly women gain access to GO care and initiate cancer treatment. The COVID-19 pandemic seemed to exacerbate pre-existing barriers to accessing GO care, especially for Black patients. Interventions to mitigate social determinants of health and assist patients with unmet social needs are urgently needed to achieve equitable access and delivery of GO care.

Factors associated with delay in seeking care for breast symptoms

BackgroundBreast cancer is the most common cancer in women worldwide. Early detection and intervention are associated with better prognosis and survival. The study aim was to investigate the factors associated with delayed presentation among women with breast symptoms.MethodsAfter ethics approval, a cross-sectional study was conducted from January to October 2020 in women with new breast cancer symptoms at their first visit to our clinic. The “Delayed Presentation” questionnaires in the Malay language were used and distributed among the participants. Demographic data and presentation time were recorded. Presentation time was defined as the duration of symptoms prior to visiting any health care facilities. Respondents with presentation times > 90 days comprised the delayed group. The potential factors associated with the delayed presentation were analyzed using cross-tabulation and multiple logistic regression.ResultsThere were 106 respondents to the questionnaire, with a mean age of 34.0 (SD: 11.2) years, and 73.6% (n = 78) were < 39 years old. A total of 35.8% (n = 38) visited the local government clinic first and only 28.3% (n = 30) came to the BestARi clinic directly. The reasons for presentation were a palpable breast lump on breast self-examination (75.5%, n = 80), mastalgia (15.1%, n = 16), nipple discharge (5.7%, n = 6), skin changes (0.9%, n = 1), and others (2.8%, n = 3). Among the respondents, 10.4% (n = 11) had alternative treatments prior to presentation to a hospital. The mean presentation time was 98.9 (SD: 323.7) days. Most of the participants (61.3%, n = 65) presented to us within 1 month. The delayed presentation group accounted for 19.8% (n = 21) of the respondents. The factor that was significantly associated with delayed presentation was the participants’ perception of symptoms as not dangerous (adjusted OR 3.05, 95% CI 1.11, 8.38).ConclusionsThe percentage of delayed presentations among our patients was lower than the percentage reported in a previous study. Interpretation of a symptom as harmless by the respondent was the only factor significantly associated with delayed presentation.

Impact of COVID-19 on Nurse Practitioner Practice and Patient Presentation in Ontario: A Qualitative Study

Aim: To highlight the impact of the COVID-19 pandemic on nurse practitioner (NP) practice and their patient populations.&#x0D; Background: Across Canada, the pandemic has caused strain on the health care system, health care providers, and patients. Many NPs continued to provide care to their patients via virtual methods as they were not permitted to assess patient in office. Lack of direct physical care was detrimental to both NPs and their patients.&#x0D; Methods: A survey was distributed to 2,094 NPs practicing in Ontario between May and August 2020. After quantitative analysis a qualitative phase was conducted that involved one-on-one semi-structured interviews with 14 NPs who completed the survey and agreed to follow up.&#x0D; Findings: The COVID-19 pandemic has had many impacts on patients and health care workers. Specifically, this study has found that NPs and patients have encountered many obstacles, such as isolation. Additionally, patients have delayed seeking care resulting in various disease progression due to concerns regarding contracting COVID-19. Finally, patients have experienced a decline in their mental health during the pandemic due to factors such as isolation.&#x0D; Conclusion: The effects of the pandemic have been detrimental for both patients and providers as demonstrated in the interviews with NPs in this study. Follow up studies should explore the long-term effects of the pandemic.

Assessment of factors associated with pre-hospital delay in seeking medical treatment among patients with myocardial infarction admitted in selected hospital of Kolkata, West Bengal

Myocardial Infarction is a medical emergency which need prompt and early treatment, and delays in seeking care can have adverse consequences on patient’s outcome. Hence a descriptive study was conducted to assess the factors associated with pre-hospital delay in seeking medical treatment among patients with myocardial infarction. Descriptive survey approach was adopted to collect data from 188 subjects selected by non-probability purposive sampling technique. Semi structured interview schedule was used to collect data. Findings revealed that in the aspect of contextual factors, among 188 subjects, majority (44.6%) subjects delayed the treatment because the distance from home to hospital was too far whereas significant people (22.8%) delayed because the symptoms came and went away. In relation to cognitive factors, majority (52.6%) of the subjects delayed because they perceived that the symptoms originated from gastric upset. Similarly in relation to behavioral factors, maximum (49.4%) of the subject delayed because they tried to eliminate the symptoms by doing other activities and taking self- medication. The findings of the study have several implications in nursing. Hence the researcher recommends to undertake similar research in a large group and various interventions can be developed by the nurses to reduce the pre hospital delay in seeking medical treatment in such a disease.

Americans' Awareness of Access Changes and Utilization of Telehealth During COVID-19: A Survey in the United States.

Background: We examine how and why Americans have experienced interrupted health care during the COVID-19 pandemic and measure awareness and usage of expanded benefits offered by health insurers and employers. We use an expanded concept of health literacy to include knowledge of access conditions and consider if patients' knowledge of the health system may relate to utilization of care. Methods: We conducted an online survey of 451 U.S. adults in September 2020, asking respondents about their health care experiences since March 1, 2020. This survey measured usage of medical care and awareness of the efforts made by government, private insurers, and employers to increase access to benefits such as telehealth services, well-being and mental health programs, and new prescription options. Results: The most common reasons cited for postponing or skipping medical appointments included fears over COVID-19 exposure, following local restrictions, or wanting to preserve resources for those with COVID-19. Our survey also finds that many Americans are largely unaware of whether they have access to expanded benefits implemented during the pandemic. Critically, respondents who recalled telehealth and prescription medication benefits being promoted were more likely to report using such benefits. Conclusion: This research suggests that greater attention to health literacy can help promote participation in the system by patients and has the potential to lead to improved health outcomes and greater adherence to treatment plans. Telehealth may offer patients increased opportunities to consult with their physicians for ailments that they might otherwise have delayed seeking care.

Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop

ABSTRACT Background Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. Objective To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. Methods A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. Results Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider’s knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. Conclusions This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.

Prevalence, Characteristics, and Determinants of Suboptimal Care in the Initial Management of Community-Onset Severe Bacterial Infections in Children

Assessment of the quality of initial care is necessary to target priority actions that can reduce the still high morbidity and mortality due to community-onset severe bacterial infections (COSBIs) among children. To study the prevalence, characteristics, and determinants of suboptimal care in the initial management of COSBIs. This prospective, population-based, cohort study and confidential enquiry was conducted between August 2009 and January 2014 in western France, a region accounting for 15% of the French pediatric population (1 968 474 children aged 1 month to 16 years) and including 6 pediatric intensive care units (PICUs) and 35 emergency departments. Participants included all children aged 1 month to 16 years who died before PICU admission or were admitted to a PICU with a COSBI (ie, bacterial sepsis, including meningitis, purpura fulminans, and pulmonary, osteoarticular, intra-abdominal, cardiac, and soft-tissue severe infections). Data were analyzed from March to June 2020. Suboptimal care determined according to evaluation of 8 types of care: (1) the delay in seeking care by family, (2) the physician's evaluation of severity, (3) the patient's referral at the first consultation with signs of severity, (4) the timing and (5) dosage of antibiotic treatment, (6) the timing and (7) volume of fluid bolus administration, and (8) the clinical reassessment after fluid bolus. Two experts assessed the quality of care before death or PICU admission as optimal, possibly suboptimal, or certainly suboptimal. The consequences and determinants of certainly suboptimal care were identified with multinomial logistic regression and generalized linear mixed models. Of the 259 children included (median [IQR] age, 24 [6-66] months; 143 boys [55.2%]), 27 (10.4%) died, and 25 (9.6%) had severe sequelae at PICU discharge. The quality of care was certainly suboptimal in 89 cases (34.4%). Suboptimal care was more frequent in children with sequelae (adjusted odds ratio [aOR], 5.61; 95% CI, 1.19-26.36) and less frequent in children who died (aOR, 0.16; 95% CI, 0.04-0.65) vs those surviving without sequelae. Factors independently associated with suboptimal care were age younger than 5 years (aOR, 3.15; 95% CI, 1.25-7.90), diagnosis of sepsis with no source (aOR, 5.77; 95% CI, 1.64-20.30) or meningitis (aOR, 3.39; 95% CI, 1.15-9.96) vs other severe infections, and care by a primary care physician (aOR, 3.22; 95% CI, 1.17-8.88) vs a pediatric hospital service. This study found that suboptimal care is frequent in the initial management of COSBI and is associated with severe sequelae. The paradoxical association with reduced risk of death may be explained by an insufficient adjustment on bacterial or host intrinsic factors. Management could be optimized by improving the quality of primary care, especially for young children.

Timely health care seeking and first source of care for acute febrile illness in children in Hawassa, southern Ethiopia.

BackgroundTimely health care seeking with access to quality health care are crucial to improve child survival. We conducted a study which aimed to identify factors influencing timely health care seeking and choice of first source of health care in Ethiopia.MethodsA total of 535 caregivers who sought health care for febrile children aged under 5 years at a tertiary hospital, and one urban and two rural health centres in Hawassa, southern Ethiopia were recruited to participate in the study from August to November 2019. Caregivers were interviewed using pretested structured questionnaires on socio-demographic and clinical factors to identify associations with health care seeking practice and first source of care, and reasons for particular practices. Delayed care seeking was defined as seeking care from a health facility after 24 hours of onset of fever.ResultsOf 535 caregivers who participated, 271 (50.7%) had sought timely health care; 400 (74.8%) utilized a primary health care (PHC) facility as first source; and 282 (52.7%) bypassed the nearest PHC facility. Rural residents (adjusted odds ratio (AOR) 1.85; 95% CI 1.11–3.09), and those who reported cough (AOR 1.87; 95% CI 1.20–2.93) as a reason for consultation were more likely to delay seeking health care. While caregivers were less likely delayed for children aged 24–35 months (AOR 0.50; 95% CI 0.28–0.87) compared to infants. Utilizing higher-level hospitals as the first source of care was less frequent among rural residents (AOR 0.15; 95% CI 0.06–0.39) and in those with no formal education (AOR 0.03; 95% CI 0.01–0.27). Those having a longer travel time to the provider (AOR 2.11; 95% CI 1.09–4.08) more likely utilized higher hospitals.ConclusionWe identified a need to improve timely health seeking among rural residents, infants, and those presenting with respiratory symptoms. Improvements may be achieved by educating communities on the need of early care seeking, and ensuring the communities members’ expectations of services at each level consistent with the services capacity.