The results of the study indicate that of the 162 clients studied, the proportion that had low level of orthopaedic use was 59 percent while the other proportion for high use was 41 percent and this difference was not statistically significant.
The proportions cited in this study are higher than those reported in Canadian Studies in Canizares (2014), where hospital visits were at 10 percent. The proportions found in our study are comparable to other studies regarding revisits especially to the emergency visits for MSDs because of the need to address recurrent orthopaedic care needs, even though they were not dichotomised (Dy, 2015).
Besides, high use must have been evident in this hospital based survey due to the fact that some Musculoskeletal Disorders tend to take longer than others to resolve. Depending on the sight of injury, the disease, the type of bones, muscles, tendons and /or ligaments affected, patients may stay longer in hospital and might need to come more often than others for review (ibid). In addition, the ability of the client to get better due to their level of immunity and the nutritional status of the client, could also have a bearing on the likelihood of being high users and this needs to be explored in the future.
Notwithstanding the above, this study is still relevant to the attempts to project MSDs in the public health realm in developing countries in that it has established that access to and utilisation of orthopaedic services is a national challenge and also a global one. It affects both the developed and the developing countries, even a lower middle income country like Zambia.
The level of use was significant by service type: In particular, the final model demonstrates that physiotherapy clients were 84 percent less likely to use orthopaedic services compared to clients from the orthotic and prosthetic workshops and this difference was statistically significant with a p- value of 0.01. This implies that, while certain MSDs are acute and require immediate attention regardless of options, other conditions are chronic and more appointments are made to ensure that the healing process takes place, as it is with conditions requiring physiotherapy. With the chronicity of conditions, mostly addressed in physiotherapy sessions, there is also a tendency of clients to miss sessions and only resurface when in great pain. Additionally, decisions are made by the caregivers and or guardians of the children and young people, who were the primary target group. The parents had transport challenges in most instances and most of the children and young were dependents who could do little in terms of contributions to their own care. This means that there is need to address retention in care for the management of chronic conditions. That levels of use for physiotherapy clients can be enhanced if the orthopaedic needs of clients and the services provided are matched.
Fractures, falls –falling from mango trees, Road traffic accident victims, cerebral palsy; congenital anomalies and amputations were among the top conditions in the study. These findings are similar to other studies, although there could be slight seasonal variations for children falling from trees (Park, 2015).
Client demographic and social characteristics have a bearing on health service utilisation in general as observed in other studies (CSO, 2014). In our study, the variables in the final model included age, sex, area of residence and Health Insurance. Unlike Clinchi’s study in 2009, age and sex were not significant determinants of orthopaedic services utilisation among young people in Lusaka, Zambia. In other words, there was no evidence of an association / relationship between levels of orthopaedic services utilisation and age, as well as no sufficient evidence of an association between levels of orthopaedic service utilisation and sex and age in this study. Nonetheless, it is worth noting that as age increased within the age groups, Orthopaedic service utilisation tended to also slightly increase in absolute figures. Our finding could mean that MSDs are varied, usually affect people of all ages, including children and young people, similar to the worldwide situation as observed by the World Health Organisation in 2017. However, for the Zambian case, this can only be ascertained in a large scale nationwide survey with all age groups including those above 24. This finding is still important due to the fact that Zambia has a youthful structure. With Zambia having a youthful population structure, the assumption is that this could also be a reflection of the fact that large populations of young people are likely to contribute to high morbidity levels as captured by the Ministry of Health in the D 70 indicator of diseases (MOH guide on quality assurance) and the trend in incidence from 2011 to 2015 noted in the National Health Strategic Plan of 2017 to 2021. Future demographic surveys should have indicators on common MSDs among the non-communicable diseases to ascertain the population level gaps if any.
With regard to the relationship between sex of a client and level of utilisation of Orthopaedic services, it means that where access to and utilisation of orthopaedic services is concerned in a hospital setting, there was no discrimination on the basis of sex for the particular age categories studied. This finding is contrary to other studies like that of Seidenberg et al (2014) which showed a significant relationship between sex and the utilisation of hospital resources.
This study established that there is an association between the area of residence and level of utilisation of orthopaedic services, in particular that this difference [OR 0.14, P < 0.0001] in the utilisation of orthopaedic services implies that MSDs are of public health importance: in that the majority of the population tends to be young and live in resources constrained environments in high density areas. While their counterparts in low residential areas use orthopaedic services less, they tend to use them more (Wyss, 1999). This finding is consistent with findings in other studies that note that residents in high density residential areas, peri- urban, experience high levels of morbidity due to preventable diseases but do not have specialised health care in their communities and tend to go to a central one, as a result of poor urban regional planning (DESA, 2013). This could be a reflection of the fact that health centres which are close to where people live do not offer specialised services like orthopaedic services. Simple tasks like suture removal and change of POP, are among the cases handled at the referral hospital instead of being seen at local facilities. In most instances, the residents in low density areas tend to be from families that can afford private care for orthopaedic conditions at home and abroad, hence a wider choice. In some instances, health officers are engaged to provide care at home in low density residential settings.
This has implications of policy, to ensure that at least first level hospitals should have some form of quality basic Orthopaedic care and attain the idea of bringing quality health services as close to the community as possible. Notwithstanding the above, this finding is also an indication that the targeted interventions are working, that there is preferential option for the poor and vulnerable members of the community to access quality orthopaedic services, albeit far from their homes.
This study established that Health Insurance was a determinant of orthopaedic services utilisation, similar to studies on Household Health expenditure Surveys noted in the literature review section, and assertions by Fletcher, (2016). Clients without health insurance were 83 percent less likely to use orthopaedic services compared to those with Insurance and this difference was statistically different at p = 0.003. Health insurance is important in access to and utilisation of specialised services. Although the children and young people themselves in some instances were not required to pay (St JPII,2016) the resources mobilised and donated by the various NGOs and groups inherently acted as facilitators of orthopaedic services utilisation but these can only cover a few. Given that few are actually insured, this form of Social Protection can act as an insurance system thereby reduce population health risk and its effects (Hangoma, 2017). It is hoped that future studies can also be done on the effect of current social protection measures in place with the support of cooperating partners, on increasing access to and utilisation of orthopaedic services and /or improving the quality of life in the country. It is worth noting that insurance claims did not cover all the orthopaedic services, i.e. devices, offered in the continuum of care even through there was differential levels in utilisation between those with insurance and those without insurance .
Enabling resources and orthopaedic service related attributes
This study has established that human resources for orthopaedic service provision for the target group in this study was scare. While demographic and epidemiological transitions are driving changes in population based health threats like high incidences of Musculoskeletal disorders, around 67 per 100 as highlighted in the strategic plan of the Ministry of health in Zambia (2017–2021), there are still limitations in the human resources pillar. These findings are similar to (Derbew, 2016 and Sampa, 2017) above. This in turn is a great barrier in responding to the MSDs threat. For both institutions and indeed for the county as a whole, there are widespread shortages, especially for Orthopaedic technologists. Although for the individual hospitals there are better doctor to client ratios at the St John Paul II compared to the UTH, the overall the human resource to population ratios are abnormally high in the study site as a whole. This brings into question whether the quality of services offered are of world class standard and can reduce medical evacuations outside the country. More studies are needed in this area.
The position of this paper is that health policy on human resources for health must take into account World Health Organisation guidelines to reduce the denominator to figures less than the national population i.e. from 15,900,000 to about 80,000 for those requiring assistive orthopaedic devices and from 15,900,000 to about 800,000 for general health services as cited in the National Health Strategic Plan 2017–2021, for a third level hospital.
Although there is evidence that something is being done about addressing the human resource challenges through the enhancement of Public/ private partnerships such as training programme at the University of Zambia in Collaboration with Ottobok; training of staff in trauma by the Israelis and having surgeons as fellows under different programmes, it will take a number of years before the actual fruits can be seen. Careful, Incremental implementation of programmes and government commitment is required to address service delivery for better outcomes in orthopaedic care. All things being equal, the advantage is that a step has been taken in the right direction to put in measures that will help to address the shortages.
Referral systems
Referral systems in the context of orthopaedic service provision ought to be well defined. There is a general assumption that due to the nature of the cases handled, only orthopaedic technocrats should be involved as can be deduced that most referrals are just within health sector: On one hand, this can help orthopaedic service providers to mingle with like-minded staff and explore niches to scale up capacity building in orthopaedic care at local levels (Bruce, 2017) using WHO and other relevant guidelines. On the other hand, this, can be construed to mean that there is some level of disregard of the fact that clients are social beings in nature, with a pleural of needs that cannot be meet by one sector. Social Welfare department, faith based groups, the private sector and others need to be engaged so that diverse welfare, financial, psychological and training needs are met.
Like it has been done in other sectors, overall, there is need to undertake bottleneck analysis, do mapping and identify gaps in services delivery and referral systems. This should be between communities and service providers for (state and non-state) for MSDs continuum of support and human rights protection if need be. Ideal terms of reference can be drawn in such a way that clients even in resources constrained settings, can get an adequate standard of orthopaedic care with dignity from many players in networks.
Client follow up
This study has established that loss to follow up is a barrier in achieving sustained positive outcomes for patients in Orthopaedic services. This, ultimately, negatively affect optimal service utilisation if others in the community do not see good results. Given the fact that hospitals are always resource constrained, mechanisms for client follow up from the referral hospitals is periodic and tended in the past to be centred on non-state actors’ initiatives such as FLYSPEC activities cited in Makasa et al (2010) for the UTH. While follow ups for clients within some areas of Lusaka are done on specified days at the St. John Paul II. With a total surface area of 752,612 square kilometres and a population of 15,900,000 million people (2016 CSO projection), some areas are very sparsely populated in Zambia. In addition to topographic characteristics of some areas, this is a challenge in reaching the unreached through outreach services. However, this challenge can to some extent be surmounted if linkages to primary health care facilities which tend to be closer to communities are made. These could be equipped to handle some post-operative care among other issues.
Gaps in Monitoring
There is a gap in defining and gaining consensus on key MSDs indicators to measure success /results, and this gap was very evident for the UTH similar to findings in other studies(Seidenberg, 2014) .Each orthopaedic centre has its own registers and report format. Except for the orthopaedic workshops, data collected on clients is quite varied. In future, the commitment to monitor and measure results will assist in knowing where they are and /or will be. While it is well appreciated that there are many MSDs, as earlier noted, tracking changes in the population served should not be compromised by the absence of specific deliverables. Reports should be submitted to the information office on agreed times.
Cost
With regard to cost, it was established that for clients aged 5–18 under the study, orthopaedic services were offered free of charge at the SJPII orthopaedic mission hospital. The service providers said that the cost of service per person was sometimes between K1, 500.00-K3, 500.00 and that it depended on the condition of the patient. When surgical procedures were done, the cost ranged from K15, 000.00 to K18, 000.00. The amounts involved might sound reasonable if one is to obtain world class quality orthopaedic services. Although there was no proof of an association between the level of use and the cost of the service and or income in the quantitative analysis, it can be deduced that clients whose incomes are way below these brackets who are not targeted with support to assess the services do not actually use them. Qualitative studies show that the poor are unable to access, ultimately use health care services and rehabilitation ( (Matt, 2014)- one of the services in the continuum of orthopaedic care.
Besides, if on average it costs about K9, 655.00 per person to bring about better treatment outcomes for the young people, the idea of rigid government grant can be said to be not very helpful in attaining quality services at the UTH where out of pocket expenditure is incurred, even in the context of free services.
This is also an indication that there is out of pocket expenditure as a result of trying to access orthopaedic services. This finding is consistent with research on household health expenditure surveys conducted in Mauritius, Kenya and Zambia noted in the literature review section. While it is appreciated that in a free market economy there is limited government intervention and other actors come in, health is a public good needed in society weather profitable or not.
Despite not being able to establish all the cost centres in the area of study, the importance of this research is that is established the existence of resource gaps faced by the hospitals in their quest to provide orthopaedic services. This in turn mirrors the fact that there are a lot of unmet needs in this sector. There is, therefore, need for greater collaboration between and among government and partners in building sustainable financing mechanisms. Investments in addressing MSDs must reflect the policy recognition that the conditions are among the top ten causes of morbidity. Adequate financing will go a long way in addressing the unmet needs and avoid late presentation and eventually, improve the health of young people who will later become productive members of society.
Perceptions and experiences of the participants
Parents in the study had difficulties in understanding the nature of their children’s condition. This can be due to the fact that there are many theories surrounding the occurrence of musculoskeletal disorders, similar to difficulties highlighted in a study on early outcomes of Ponseti management of talipes (Sonkwe, 2009). Understanding of the situation can greatly help one to adopt health seeking behaviour.
What is interesting in this study is that despite little understanding, the parents still brought their children to the hospital for reviews, exercise and other relevant orthopaedic services. This can be explained using the incentives theory. That parents may not yet see the benefits but they are happy, intrinsically rewarded, to be doing something to help their children on the road to wellness. In terms of health care, this is important in that it builds ones’ esteem and is intrinsically rewarding to the care giver as they have the knowledge about what they can do to help (Park, 2015).
It is good to note additionally that, the education done by health care workers on how to care for their children increases their skills and/or mastery over a previously difficult situation and is a form of extrinsic reward. This finding is similar to other studies where this was done (Pietrucin-Materek et al, 2015). Parental education is important in the success of treatment process. Parent information hand-outs can be prepared and other innovative ways to reduce the stress that comes with parenting children with short term and /or long term orthopaedic conditions. Young people are well informed and understand their situation, as noted in the FGD above, except in one instance. In spite the hospitals having already put in some measures to improve access to Orthopaedic services like outreach services and free services, the feedback in the FGD and parent interviews that the cost of the services and materials are high, including transport challenges, is a matter of concern and could have a negative impact on client satisfaction and acceptability of orthopaedic services.
Although there could have been a difference in the clinical diagnosis, of their child, it was good to note that most parents rated their children as being good, in fact better than the other children they saw. This means that it is important to have exposure to the environment around one and a possible practice measure is to have parent groups in order to educate them in their free time, on care for the children at home. Sometimes, even if they are willing to continue with simple exercise or look out for something unusual at home, they are more likely to try out what their peers are doing. Most of the key barriers associated with the women folk included little or no information about practices and other essential health actions; cultural beliefs; distance to health facility and costs of transport and fear of marital discord if they discussed health matters at length with their husbands and broken families were noted. Similar to other studies, parenting of children with chronic conditions comes with stress (Pietrucin-Materek et al, 2015).
Fathers’ support was reported in the study, under family support. Knowing that parent education was done and in other instances fathers also accompanied mothers to the hospital, this is a sign that the service providers are moving towards enablement, an important quality measure and also a way of reducing the burden of care on the women folk.
On the other hand, some of the parents had not seen any difference/benefits of using Orthopaedic services yet. This is alright too, as new entrants really are not be expected to see the results immediately while others may not be able to take note of the signs since they may be preoccupied with other care needs. Others may have experienced adverse effects, like mal unions and non-union following a fracture, especially in the case of a child that had severe osteoporosis. Here gaps exists on possibility of other conditions alongside musculoskeletal disorders.
Study limitations
Proportion for utilisation used to calculate the sample size was an average estimation based on WHO estimation of Orthopaedic appliances utilisation, the proportion of people likely to have impairments and the reported use in the developed countries of 5 percent to 15 percent. The 5 percentage point was used due to the varied nature of MSD which are categorized differently and in most instances might require use of walking aids and other appliances for considerable amounts of time. Clients from Hospitals might have more need to use the hospital as compared to the general population, however choosing a referral hospital was deemed to have better chances of giving a more general picture of utilisation since clients come from diverse parts of the country.
Purposive sampling decreases the generalisation of findings in the qualitative component. The data and responses for the study reflect the opinions and views of the institutions involved in the study, thus the researcher endeavored to presents the participant’s views in verbatim. Some records and or registers were incomplete. To avoid many missing values, restriction on the number of variables obtained was observed and the researcher relied on the electronic data bases created at the two hospitals and only in exceptional circumstances were hard copies referred to with the assistance of records clerks and nurses from the ward with whom the data requirements were shared during the study time.
