Falling through the net: An adaptive assessment of the 'Three Delays' encountered by patients seeking emergency maternal and neonatal care within a remote health system on Lake Victoria, Kenya.

In rural sub-Saharan Africa, preventable delays in accessing emergency care remain a dominant factor in maternal and neonatal deaths. The MOMENTUM study is a pragmatic cohort investigation designed to measure the "Three Delays", i.e. delays in recognizing need for care (Type 1), reaching care (Type 2), and receiving care (Type 3) within a remote island health system on Lake Victoria, Kenya. The study utilizes an adaptive methodology to provide actionable data for a locally-directed "Health Navigation" intervention. We present analysis of 56 maternal and neonatal emergency cases occurring between January 2019 and February 2020. The mean Total Delay Interval (Type 1-3) reported was 39.3 ± 32.3hours. Notably, 18 cases in this cohort resulted in a neonatal (n = 16) or maternal death (n = 2). Sub-analysis indicates significant delay interval reductions associated with involvement of a "Health Navigator" in emergency care coordination for Type 2 Delay Intervals (0.5 ± 0.3 vs. 1.2 ± 1.1 hrs., p = 0.002) and Type 3 Delay Intervals (17.9 ± 14.1 vs. 32.9 ± 33.7 hrs., p = 0.030). Prolonged delays, complex barriers, and high mortality highlight the fraught nature of maternal emergencies in this remote setting. We discuss practical considerations for application of the Three Delays model, and avenues for further investigation.

Impact of naloxone education for patients receiving buprenorphine-containing prescriptions indicated for opioid use disorder at an independent community pharmacy.

OBJECTIVES: A pilot study was conducted to identify whether an opioid education and naloxone distribution (OEND) service affected (1) willingness to accept naloxone; (2) naloxone dispensation; and (3) patient knowledge about opioids, overdose symptoms, and naloxone in patients receiving buprenorphine prescriptions for opioid use disorder (OUD). METHODS: Participants were enrolled from January 2, 2019, to February 15, 2019, in this prospective noncontrolled study when receiving a buprenorphine prescription at the study site. The exclusion criteria included prescriptions being picked up by someone other than the patient and those who were below 18 years of age. The participants completed a written pre- and postsurvey containing "Yes" or "No," "Select all that apply," and open-ended questions assessing (1) willingness to accept naloxone and (2) change in opioid and naloxone knowledge. RESULTS: Fifty-two participants were enrolled, and all completed the pre- and postsurveys. After the education, there was a not statistically significant change in the proportion of participants willing to accept naloxone from the pharmacy (28.8% vs. 36.5%; P = 0.31). In addition, there was an improvement in the proportion of participants believing that they need to carry naloxone with them (15.4% vs. 40.4%; P < 0.001). Naloxone dispensing increased 400% after the intervention implementation. Improvements in opioid knowledge also occurred. More participants correctly identified buprenorphine as an opioid (48.1% vs. 86.5%; P < 0.001), and correctly identified that methamphetamine (19.2% vs. 3.8%; P = 0.02) and cocaine (17.3% vs. 3.8%; P = 0.03) are not opioids. Of the 52 participants enrolled, 11.5% correctly identified all opioids on the presurvey, whereas 50% correctly identified all opioids on the postsurvey. CONCLUSION: Patients diagnosed with OUD who are prescribed buprenorphine may be at high risk of an overdose if they return to use; yet, few OEND programs specifically target this population. This study suggests that OEND based in community pharmacies may be a strategy to increase naloxone access among these patients.

The MOMENTUM study: Putting the 'Three Delays' to work to evaluate access to emergency obstetric and neonatal care in a remote island community in Western Kenya.

Despite worldwide improvements in maternal and infant mortality, mothers and babies in remote, low-resource communities remain disproportionately vulnerable to adverse health outcomes. In these settings, delays in accessing emergency care are a major driver of poor outcomes. The 'Three Delays' model is now widely utilised to conceptualise these delays. However, in out-of-hospital contexts, operational and methodological constraints present major obstacles in practically quantifying the 'Three Delays'. Here, we describe a novel protocol for the MOMENTUM study (Monitoring of Maternal Emergency Navigation and Triage on Mfangano), a 12-month cohort design to assess delays during obstetric and neonatal emergencies within the remote villages of Mfangano Island Division, Lake Victoria, Kenya. This study also evaluates the preliminary impact of a community-based intervention called the 'Mfangano Health Navigation' programme. Utilising participatory case audits and contextually specific chronological reference strategies, this study combines quantitative tools with deeper-digging qualitative inquiry. This pragmatic design was developed to empower local research staff and study participants themselves as assets in unravelling the complex socio-economic, cultural, and logistical dynamics that contribute to delays, while providing real-time feedback for locally driven intervention. We present our methods as an adaptive framework for researchers grappling with similar challenges across fragmented, rural health landscapes.