Barnes Kieran, Ngari Cecelia, Parkurito Stanley, Wood Leo, Otundo Denis, Harrison Robert, Oluoch George O, Trelfa Anna, Baker Clare
Centre for Snakebite Research & Interventions, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
Kenya Snakebite Research and Intervention Centre, Institute of Primate Research, Reproductive Biology Division, PO Box 24481, Karen, Nairobi, Kenya.
Toxicon X. 2021 Jul 30;11:100078. doi: 10.1016/j.toxcx.2021.100078. eCollection 2021 Sep.
Key aims of the WHO Strategy to halve snakebite morbidity and mortality include health system strengthening and training of health workers. This requires knowledge of local health system needs and capacity, health worker training needs, and factors influencing health worker decision-making in snakebite management. This study explored health worker experiences and perceptions of snakebite management, both individually and in the context of their local health system. We used a qualitative study design with semi-structured interviews (n = 14) and focus group discussions (n = 4). We employed a combination of sampling strategies aiming to achieve maximum variation among key informants within resource limitations. We recruited health workers (n = 33) of varying roles from purposively selected tier 2, 3 and 4 health facilities (n = 12) and the community (tier 1) in four sub-counties in Kitui County, Kenya. We conducted inductive thematic analysis of all transcripts. The results identified that health workers recognised snake envenoming as a time-critical emergency in which delay in care seeking, sometimes exacerbated by health system referral delays, was a major barrier to effective management of patients. Clinicians strongly voiced a need for training in snakebite management, diagnosis and antivenom administration. Unexpressed needs for training were demonstrated in traditional remedy ineffectiveness, syndromic management, and critical appraisal of treatment effectiveness. Under-resourcing in antivenom, other medication, equipment, infrastructure and staffing also challenged management. Fear of snakebite and fear of antivenom, both linked to past experiences, influenced clinical decision-making. Our findings clearly indicate a need in Kitui County for training programmes that equip health workers for clinical decision-making in snakebite management. We further identify community intervention needs to facilitate prompt presentation to healthcare, including practical affordable transport solutions, and systematic health system resourcing needs. In addition, we recommend supportive supervision and further research in response to the emotional stress resulting from managing difficult cases in under-resourced settings.
世界卫生组织将蛇咬伤发病率和死亡率减半战略的主要目标包括加强卫生系统以及培训卫生工作者。这需要了解当地卫生系统的需求和能力、卫生工作者的培训需求，以及影响卫生工作者在蛇咬伤管理中决策的因素。本研究探讨了卫生工作者在蛇咬伤管理方面的个人经验以及他们在当地卫生系统背景下的看法。我们采用了定性研究设计，进行了半结构化访谈（n = 14）和焦点小组讨论（n = 4）。我们采用了多种抽样策略相结合的方式，旨在在资源有限的情况下，使关键信息提供者之间实现最大程度的差异。我们从肯尼亚基图伊县四个分区中经过有目的选择的二级、三级和四级卫生设施（n = 12）以及社区（一级）招募了不同角色的卫生工作者（n = 33）。我们对所有访谈记录进行了归纳主题分析。结果发现，卫生工作者认识到蛇毒中毒是一种时间紧迫的紧急情况，寻求治疗的延迟，有时因卫生系统转诊延迟而加剧，是有效管理患者的主要障碍。临床医生强烈表示需要接受蛇咬伤管理、诊断和抗蛇毒血清给药方面的培训。在传统疗法无效、症状管理以及对治疗效果的批判性评估方面，显示出未表达的培训需求。抗蛇毒血清、其他药物、设备、基础设施和人员配备资源不足也对管理构成了挑战。对蛇咬伤的恐惧和对抗蛇毒血清的恐惧，都与过去的经历有关，影响了临床决策。我们的研究结果清楚地表明，基图伊县需要开展培训项目，使卫生工作者具备蛇咬伤管理方面的临床决策能力。我们进一步确定了社区干预需求，以促进及时就医，包括切实可行的经济实惠的交通解决方案，以及系统性的卫生系统资源需求。此外，我们建议进行支持性监督，并针对资源不足环境中处理疑难病例所产生的情绪压力开展进一步研究。
