Access to quality care after injury in Northern Malawi: results of a household survey

Background Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury. Methods We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked. Results Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142). Conclusion Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.