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Abstract
Background Prehospital care is a vital part of emergency medical care. Countries with decentralised ambulance systems, such as Pakistan, require patient knowledge as to when to call an ambulance and which service to call. Little is known about how patient perceptions of ambulance services affect ambulance usage in most low- and middle-income countries (LMIC). The purpose of our study was to analyse patient perspectives of the ambulance system in Karachi to understand how to improve ambulance use.
Methods Indepth interviews were conducted with 30 individuals selected by convenience sampling representing patients who came to the emergency department by private transport versus one of two of the main ambulance service providers in Karachi.
Results Similar to what has been shown in some LMIC contexts, two of the major themes that emerged which affect patient decision making with regard to ambulance use were a mistrust of the ambulance system or providers and a sense of inadequacy of the local system as compared with international standards. In addition, which has not been shown in previous studies, there was a fundamental misunderstanding of the role of ambulance services in the healthcare infrastructure.
Conclusions Insight into the main issues affecting patient decisions to use an ambulance service offers possible targets for patient education that could result in an increase in the proper usage of ambulances and thus optimise outcomes from serious injury and illness in an LMIC context.
- Prehospital Care
- Patient Support
- Trauma
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Introduction
Prehospital care is a vital part of the emergency medical system (EMS) and the overall health system. The success in terms of patient outcomes of a proper EMS system depends on many components; of particular importance is the patient component, including proper awareness of when and how to seek EMS assistance and transport. Research demonstrates that negative perceptions of ambulance services and lack of knowledge about prehospital care often lead to less use of ambulance services.1 ,2
Karachi, the largest city in Pakistan with a population of 18 million, has a decentralised ambulance system, in which each service is independently operated by a private non-profit organisation or by an individual hospital. Each ambulance service is contacted by a separate phone number, and most services in Karachi provide little to no prehospital care. In one study, only 16% of patients in Karachi were found to use an ambulance to reach an emergency department (ED).1 With high rates of cardiovascular disease, stroke and trauma, there is a substantial need for quality prehospital care in Karachi.3–5
The role of patient perceptions and awareness in operating a successful prehospital care system have been explored in developed countries; most studies call for programmes to educate the public on proper ambulance usage and highlight the overuse of ambulance services in these countries.6–8 Some studies have explored patient perceptions and awareness of EMS systems in developing countries.2 ,9 ,10 Most of these studies, however, did not approach the patient's perspective towards ambulance services by solely soliciting the patient’s point of view. This study is an initial exploration of the EMS system user perspective in a low-income setting. Building on an earlier study by Razzak et al,1 our aim was to qualitatively determine the perceptions that patients have of the EMS system in Karachi that are affecting its use.
Methods
Study setting
This study was conducted at the Aga Khan University (AKU) Hospital. AKU is a private 450 bed tertiary care facility with a 51 bed ED which sees approximately 45 000 patients per year.11 The majority of patients are from Karachi, but the hospital also receives patients from all parts of Pakistan.12
Patient population
Convenience sampling was used to recruit patients from the ED at AKU hospital. Overall, 30 patients were recruited from three different groups divided according to the mode of transportation taken to the ED for the patient's current visit: (1) 10 patients had used the Edhi Foundation ambulance service, (2) 10 patients had used the Aman Foundation ambulance service and (3) 10 patients had used a secondary form of transport.
The Edhi Foundation ambulance service was established in 1955 and is the most established ambulance system in Karachi. These ambulances are managed by a driver with no emergency response training and contain only a stretcher and, upon request, an oxygen tank.12 The Aman Foundation ambulance service was started in 2009 and currently operates 100 ambulances. These ambulances contain emergency medical equipment in accordance with international standards and have a trained emergency medical technician, driver and doctor upon request.
Interviews
The interview guide was developed in English, with structured open-ended questions.13 The initial draft was translated into Urdu and then piloted in 17 patients prior to finalising. Two research team members conducted all interviews in Urdu.
Participants were screened in the AKU ED; those that met inclusion criteria were approached. Patients with critical illness/major trauma were excluded because they were in an inaccessible part of the ED. Written informed consent was obtained in Urdu from the patients and their attendants. As per protocol, the patients were asked to participate first without their attendants. In cases where the patients needed the assistance of their attendant to participate, the interview was conducted with their support. Interviews were conducted in June and July, 2011, either in a private consultation room in the ED or by the patient's bedside. Each indepth interview lasted up to 30 min.
Analysis
All indepth interviews were recorded and transcribed in the local language, Urdu. The interviews were translated into English, but the majority of the analysis was done using the original transcripts in Urdu in order to preserve nuances in the patients’ responses.
The Urdu transcripts were entered into NVivo 9 (QSR International, 2009). The interviews were independently coded by two study investigators and overarching themes were extracted.
This study was approved by the Institutional Review Board at Johns Hopkins Bloomberg School of Public Health and by the Ethical Review Committee at the AKU Hospital.
Results
Mistrust of ambulance services in Karachi, a belief in the inadequacy of ambulance services in Karachi, and a demonstrated lack of knowledge about ambulance services and the role of prehospital care among respondents were three major themes that emerged in this study.
Mistrust
One reason for the mistrust of ambulance services is the idea that ambulances pose a risk towards personal safety. Prevalent perceptions included a fear of reckless driving or of robbery by ambulance drivers.
Fine, it's an emergency, there's a patient… but this does not mean that [they] can go hitting ten people. There's a lot of rough driving going on. (Personal Transport)
In carrying [people] back and forth….the ambulance [providers] rob you, and this is also a reason to be scared. (Personal Transport)
Singh et al2 showed that patients believed that ambulance drivers were overcharging them for the driver's own benefit, and this perception was present in Karachi as well.
I just want to tell you that it was a 10-minute route from Tahir medical center to here. They charged 1500 rupees [∼$17.20] which is too much ... (Aman Foundation)
Many respondents also believed that ambulance drivers abused the siren. This perception causes a large proportion of drivers in Karachi to not yield to ambulances on the road.
I've seen one thing often, that an ambulance has a siren for an emergency, and people no longer trust it because it is being used incorrectly… when it is being used correctly, then people aren't trusting it, people aren't giving [ambulances] space... (Personal Transport)
The fact that ambulances sometimes have a delayed response time in Karachi is also another reason for mistrust in the ambulance system. A previous study showed that attendants preferred moving patients themselves through a form of secondary transport.1 ,2 The most common forms of secondary transport in our study were private cars, taxis and rickshaws; one patient and his attendant even walked to the ED.
My father-in-law was not breathing, so I called [the ambulance]. Their point was just at the corner… I think they didn't come for 25 minutes…the doctor wrote that a dead body was brought, but when did this death happen? The half hour that we wasted, did it happen then? (Personal Transport)
Many respondents claimed that since ambulances do not come on time, seeking out an ambulance and directing it to the point of need is the quickest way to summon one.
It is true that if you call them … they don't often come. If you call them from the hospital, etc. then sometimes they take half an hour, an hour, maybe even one and a half hours… If you go and get them yourself, then they come in 10–15 minutes. (Edhi Foundation)
Inadequacy
Previous studies showed the dissatisfaction of many patients with the quality of their prehospital services.1 ,2 Respondents in our study suggested that the ambulance system in Pakistan should be modelled after those in other countries.
We should look at other countries and bring all those things here. Like here they have a [van] and they've turned it into an ambulance. Over there an ambulance is such that it is only for ambulance services. (Edhi Foundation)
There was a wide range of expectations of ambulance quality in Karachi. Whereas previous studies showed that inadequacy was a reason for not using ambulance services in developing countries,2 ,7 ,11 ,12 some respondents were satisfied with ambulance quality in Karachi.
The ambulance had everything in it, nothing more can be done. I'll just say that the thing for breathing, that was there. They had air conditioning too (it was broken today). (Aman Foundation)
Other respondents, however, had higher expectations of what equipment and resources should be available in ambulances.
First of all, they should have paramedical staff. And they should have everything from oxygen to a suction machine. (Personal Transport)
Some respondents commented positively only on non-medical aspects of the service.
I think Aman has more advanced equipment, like it has air conditioning and such facilities inside, so that's good! (Aman Foundation)
Others travelled in some of the more advanced ambulance services in the city, but were not able to appreciate the equipment present.
They should have an oxygen mask, medicines, there should be a doctor…all of these things should be there and aside from that there should be a nurse who can give treatment on the way as well. (Aman Foundation)
Only a few patients were able to appreciate the differences in the resources or equipment available in a few of the ambulance services in Karachi.
This is the first time we are taking Aman and they were inside with us during the initial emergency treatment here too…I was very surprised by how they shared everything with the doctor here, and I really liked seeing that. They are well trained. (Aman Foundation)
A study from Zimbabwe showed that deteriorating economic conditions there led to deterioration of the EMS system.6 Similarly, many of our respondents viewed the problems of ambulance services as coming from the problems of society.
But [the ambulance provider] knows that if I keep some medication [in the ambulance] it will get stolen. This is Pakistan's system, unfortunately. (Personal Transport)
Lack of awareness
The major ambulance services in Karachi publish their numbers in the city's major newspapers on a daily basis, and all ambulances have their contact numbers on the vehicle. However, many respondents still did not know how to contact an ambulance.
Someone we know called them, [my husband] was sick and my son is young. (Edhi Foundation)
I guess we approach them from a hospital; I don't have their number. (Personal Transport)
A previous study in Karachi showed that many calls to ambulances were for transporting bodies.1 When respondents were asked about what types of patients should go in an ambulance, the view that ambulances were only used to transport the dead or the critically ill was pervasive.
If there's a major injury, if there's blood loss, if there's a heart problem, or if the patient is not in their senses… (Personal Transport)
Ambulances in our culture are used for very severe conditions, they are most probably not used for casual treatment or transport... (Personal Transport)
Respondents expressed the discomfort felt by many patients when using an ambulance because it made a certain statement about their condition.
Firstly it doesn't have that good of a feeling, it gives you a bad feeling that a person is going in an ambulance. (Personal Transport)
This idea that ambulances are used only for very critical conditions was further confirmed when many respondents were asked if they had used an ambulance during our screening process and they responded:
God Forbid!
Why, is everything ok?
No, his condition was not that bad!
Singh et al2 showed that patients often viewed ambulances as being specific to ‘very important persons’ or the upper class. Our respondents held the opposite viewpoint.
People who maybe have issues with their own [form of transport] are the only ones to use an ambulance, other than that, no one. (Edhi Foundation)
This stereotype leads to the perception that an ambulance service is not actually a medical facility, but rather a transport service, comparable with other forms of transport such as taxis.
Often, the lower class thinks that instead of a taxi, I'll take an ambulance, because the poor things go out of necessity to the doctor… they'll have to pay doctors, rickshaw drivers, taxi drivers too, so [they] save. (Personal Transport)
Discussion
Our study qualitatively examined patient perspectives about ambulance services to better understand the barriers to their usage in Karachi. We showed that similar to previous studies, the mostly negative patient perceptions of ambulance services stemmed largely from a sense of mistrust in the ambulance system and a belief in its inadequacy.1 ,2 ,10 ,14 ,15 However, unlike many prior studies, our study also demonstrated a general lack of awareness about ambulance services in Karachi and about their role in the proper patient care.
In Karachi, despite the presence of well-equipped ambulance services that meet international standards of care such as the Aman Foundation ambulances, most respondents viewed Pakistan's ambulance services as inadequate, especially when compared with ambulance systems in other countries. Most respondents had never experienced an ambulance system in another country; they simply assumed that it was superior to Pakistan's. In addition, most patients in Karachi did not trust local ambulance services. They believed that the ambulance would not come, that it would be late or that it would take advantage of them. Mistrust of the ambulance system in Karachi leads many residents to not give way to ambulances. The belief in the abuse of ambulance sirens was particularly interesting because it actually increased delays in the arrival times of ambulances to their destinations, further increasing mistrust in the EMS system.
In contrast to findings from other studies, respondents in Karachi felt that ambulance services were more appropriate for those with limited resources.2 While those who did use ambulances felt that the ambulance drivers were overcharging them for the drivers’ own benefit, the societal view towards ambulances was that they were used by those who could not afford to take another form of transport. One possible explanation for this reasoning could be that many of the perceptions that patients hold towards the EMS system in Karachi are based on their perceptions of the Edhi Foundation ambulances. The Edhi Foundation is seen as a ‘home for the poor’ and, in Karachi, the word Edhi is almost synonymous with ambulance.12 However, because of their limited resources and the association of Edhi with the poor, Edhi Foundation ambulances may have actually contributed to the belief in the inadequacy of ambulances in Karachi as well as to the fundamental misunderstanding of the role of ambulance services as a form of transport for the poor rather than as a form of prehospital care.
In order to improve the use of the system of prehospital care in Karachi, education regarding how appropriate care delivered in a properly equipped ambulance can impact the outcome of a patient is critical. The lack of knowledge about the availability of ambulance services in Karachi and the viewpoint that an ambulance is simply a form of transport similar to a taxi point to a lack of awareness about the role of ambulances in providing prehospital care. Most respondents in our study emphasised speed in the decision to choose a form of transport to the hospital, and very few were able to appreciate proper medical equipment in an ambulance when it was available. These facts indicate a lack of knowledge about the importance of prehospital care and a lack of awareness of what prehospital care consists of, with many respondents listing factors such as air conditioning and ambulance size as particularly important. Many of the reasons cited for mistrust of ambulance services by respondents in our study further point to a lack of knowledge about ambulances in Karachi. The idea that ambulances abuse their sirens and that ambulances are not punctual are problems that are intricately linked, and with more awareness of such problems, some of the reasons for mistrust of ambulance services could disappear. Overall, this lack of knowledge and awareness about prehospital care in Karachi leads to delay in involving the EMS system until late in the illness spectrum, thereby missing earlier opportunities to intervene and assist in the care of the patient.
One limitation of this study is that respondents were recruited from the AKU Hospital, a private hospital in Karachi. Though we received patients of all social strata, our sample may have been skewed towards the wealthy. Second, only two ambulance services in Karachi were chosen. Although the two represent opposite ends of the spectrum in terms of years in service and availability of equipment/resources, it would be interesting to expand this type of study to include users of different ambulances. Finally, we interviewed only 30 individuals in this study. Broadening the scope of the number interviewed would add further depth and variability to the analysis.
We present based on this study three important influences delaying the timely and appropriate calling of an ambulance to respond to an emergency in Pakistan. The influences of mistrust in the ambulance system and its providers, a feeling that local systems are inadequate, and a fundamental misunderstanding of the role of ambulances in prehospital care result in a delay or lack of desire to call an ambulance even when a health emergency is recognised. This paper gives a unique insight into people's perceptions of ambulance services in a developing country setting. Improvements and changes to the ambulance services themselves will have limited impact unless people's perceptions about the importance and role of ambulances in prehospital care are modified concomitantly. With attempts to improve emergency and prehospital care globally, it is important to keep in mind that a prehospital system must be tailored to the population that it serves.16 This study highlights some of the areas in which patient education must focus in order to improve the image and use of ambulance services in Karachi and other resource-limited settings.
Acknowledgments
We would like to acknowledge Rubaba Khan and Sana Siddiqui for their contributions to data collection for this study. We also acknowledge the providers and staff at the AKU emergency department, and the Edhi and Aman Foundations for their support. Finally, we deeply appreciate the time and effort given by the patients and their families/attendants who participated in this study.
References
Footnotes
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Contributors AC is responsible for the overall content of the article and guarantees its content. AC, JR and AH conceived of the study and were responsible for overall oversight and technical guidance. AC and RK applied for funding support. MB provided overall day-to-day supervision. KE directly supervised RK as they did the interviews. AC and KE led the data analysis with the direct participation of RK. All authors contributed to the data analysis and final manuscript.
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Funding This study was funded by the Woodrow Wilson Undergraduate Research Fellowship Program at the Johns Hopkins University (Grant Account Number 80025083). The funding body did not participate in the study except to provide financial resources.
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Competing interests None.
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Ethics approval Johns Hopkins Bloomberg School of Public Health, Aga Khan University. Written informed consent was obtained from all study participants.
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Provenance and peer review Not commissioned; externally peer reviewed.