Understanding Delay in Accessing Specialist Emergency Eye Care in a Developing Country: Eye Trauma in Tanzania

Abstract

Purpose: To determine the extent and reasons for delay in accessing specialist eye care following a significant eye injury.

Methods: Mixed methods study involving 93 consecutive admissions to Kilimanjaro Christian Medical Center, Tanzania (KCMC). Semi-structured interviews were conducted and supplemented by a review of medical notes. A statistical analysis of delay and predictor variables was conducted. Framework analysis of interviews was conducted.

Results: Ninety of 93 patients took part. Significant visual loss was determined in 95.5% of affected eyes on arrival. The mean delay for treatment was 6.8 days. Of participants, 61.1% visited some health facility within 24 hours, and 82.2% within 48 hours. Injury on a weekend, using topical drops and visiting other health facilities before KCMC were independently associated with delay greater than 24 hours and greater than 48 hours, female gender with was associated with delay greater than 24 hours. Patient journeys involved key milestones and processes. Journeys were frequently “circular,” involving delays caused by repeated visits to health units unable to treat the injury, often on a health worker’s advice. Systems problems included unclear referral systems and opening times, frequent staff absence and unqualified staff deputizing. Individual health workers had an important influence on delay but their performance appeared variable. They influenced patient journeys positively when they made an accurate diagnosis, referred directly to KCMC, discussed practicalities and communicated the seriousness of the injury, the need for urgent treatment and the adverse consequences of delay.

Conclusions: There is significant delay in accessing appropriate specialist care following eye injury in Tanzania, much of which occurs after first visiting a health facility. We present a new model of delay that may help guide interventions to reduce this delay.

KEYWORDS::

• Eye injury
• Primary medical care
• Therapy delay
• Developing country
• Qualitative analysis

ACKNOWLEDGMENTS

Dr. Al-Attas and Dr. Williams are joint first authors on this article. Dr. Yvonne LeFeber, PhD, provided important help in designing the guidelines for the interviews.

No specific funding was obtained for this project. Dr. Al-Attas undertook this work unfunded as part of his MMed qualification in Ophthalmology. Dr. Williams, Dr. Pitchforth, Dr. Lewallen and Professor O’Callaghan received no funding for their work on this project. Dr. Williams undertook this work on a research sabbatical partially funded by the David Baum International Foundation, Royal College of Paediatrics and Child Health. Dr. Lewallen is partially funded by the Seva Foundation.

Declaration of Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.