Getting to the Emergency Department in Time: Interviews With Patients and Their Caregivers on the Challenges to Emergency Care Utilization in Rural Uganda - a Grounded Theory Approach

Objectives Karoli Lwanga Hospital and Global Emergency Care, a 501(c)(3) nongovernmental organization, operate an Emergency Department (ED) in Uganda's rural Rukungiri District. Despite available emergency care (EC), preventable death and disability persist due to delayed patient presentations. Implementation of effective EC requires assessment of socioeconomic, cultural, and structural factors leading to treatment delay. Methods We purposefully sampled and interviewed patients and caregivers presenting to the ED more than 12 hours after onset of chief complaint in January-March 2017 to include various ages, genders, and complaints. Semistructured interviews addressing actions taken before seeking EC and delays to presentation once the need for EC was recognized were conducted. Interviews were audio recorded, translated, and transcribed, enabling the interdisciplinary and multicultural research team to conduct thematic analysis utilizing a grounded theory approach. Results The 50 ED patients for whom care was sought (mean age 33) had approximately even distribution of gender, as well as occupation (none, subsistence farmers and small business owner). Interviews were conducted with 37 caregivers and 13 ED patients. The majority of interviewees (mean age 38 years) were women with a primary education. The median duration of patients' chief complaint on ED presentation was 5.5 days. On average, participants identified severe symptoms necessitating EC 1 day before presentation. Four themes of treatment delay before and after severity were recognized were identified: 1) Cultural factors and limited knowledge of emergency signs and initial actions to take ; 2) Use of local health facilities despite perception of inadequate services; 3) Lack of resources to cover the anticipated cost of obtaining EC; 4) Inadequate transportation options. Conclusions Interventions are warranted to address each of the four major reasons for treatment delay. The next stage of formative research will generate intervention strategies and assess the opportunities and challenges to implementation with community and health system stakeholders.