International Emergency Medicine
Emergency Care and Referral Among Isolated Island Populations in the Bahamas

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Abstract

Background

Isolated island populations face unique health challenges. In the Bahamas, the islands of Mayaguana, Inagua, Crooked Island, Acklins, and Long Cay—referred to as the MICAL Constituency—are among the most isolated.

Objectives

Our objective was to better understand regional emergency care needs and capabilities, and determine how emergency care can be optimized among island populations.

Methods

During the summer of 2013, the project team conducted semi-structured key-informant interviews and small-group discussions among all health care teams in the MICAL region, as well as a community-based household survey on the island of Mayaguana. The interviews and small-group discussions consisted of open-response questions related to health care services, equipment, supplies, medications, and human resources. The community-based survey examined the prevalence of chronic noncommunicable diseases (CNCDs) and associated risk factors affecting the inhabitants of the region.

Results

The average number of annual emergency referrals from each of the MICAL islands was approximately 25–30, and reasons for referrals off-island included chest pain, abdominal pain, trauma, and dysfunctional uterine bleeding. Traditional prehospital care is not established in the MICAL Constituency. Providers reported feelings of isolation from the distant health system in Nassau. Whereas most clinics have a well-stocked pharmacy of oral medications, diagnostic capabilities are limited. The household survey showed a high prevalence of CNCDs and associated risk factors.

Conclusion

Ongoing in-service emergency care training among MICAL providers is needed. Additional equipment could significantly improve emergency care capabilities, specifically, equipment to manage chest pain, fractures, and other trauma. Community-based preventive services and education could improve the overall health of the island populations.

Introduction

Island populations face unique health care challenges. Because they are often hundreds of miles from an urban center and established hospital services, providing island populations with quality care can be difficult. Isolation and a lack of infrastructure, human resources, and effective communications are common challenges 1, 2, 3, 4.

In the Bahamas, in particular, isolation and a limited number of facilities and providers affect the quality of health care. Across the over 700 islands that make up the Bahamas, health services, most significantly, are established centrally in the capital, Nassau, on the island of New Providence. Other island communities are typically served by resource-constrained health clinics and must rely heavily on off-island referrals for advanced care. Within the Bahamas, there are only 41.4 nurses and midwives for every 10,000 residents, compared to the regional average in the Americas of 71.5 (5). Additionally, with an aging population and changes in lifestyles, chronic noncommunicable diseases (CNCDs) such as obesity, hypertension, and diabetes pose an increasing challenge for the islands, accounting for 72% of all deaths (6).

The five islands—Mayaguana, Inagua, Crooked Island, Acklins, and Long Cay (MICAL)—in the southeastern part of the Bahamas island chain, make up what is known as the MICAL Constituency and are among the most remote islands in the Bahamas. Thus, providing quality health care is particularly challenging. Although each island may have a simple health clinic, care is typically not comprehensive. These island populations usually require referral to a larger island for anything but basic care. A thorough understanding of the health needs and capabilities in the region, however, is not available.

In partnership with the Ministry of Health (MOH) and other stakeholders in the Bahamas, our Division of Global Health and Human Rights at Massachusetts General Hospital (Boston, MA) assessed the current emergency health care needs on these isolated islands, and how emergency referral might be optimized. Through field-based interviews of providers, administrators, stakeholders, and a community-based survey, we sought to understand the greatest barriers to care, and to identify the CNCDs and risk factors affecting the islands. Our ultimate goal was to provide the MOH with informed, actionable recommendations for improving emergency patient care and referral for the MICAL Constituency, and also possibly for other isolated island populations.

Section snippets

Study Design, Setting, and Participants

In partnership with the MOH, we conducted a field-based emergency heath care needs assessment among providers and administrators on the islands of the MICAL Constituency. Our physician-led team traveled to the MICAL region in July 2013 and conducted semi-structured key-informant interviews and small-group discussions among local health care providers and administrators. All health care teams in the MICAL region were interviewed, including the lead nurse or physician of each of these teams.

Discussion

Over 200 miles from Nassau, the five islands of the MICAL Constituency of the Bahamas are among the most isolated in the region. Our study illustrates the many challenges present in providing essential emergency and referral services among isolated island populations. The realities of an island population—significant remoteness and limited communications, infrastructure, and human resources—all have an impact on the quality of health care. Our findings identified the needs of the region, but

Conclusion

Isolated island populations and the health care providers serving them face unique challenges that complicate emergency care services and referral. In the MICAL region of the Bahamas, providers report a sense of isolation, some limitations in equipment and supplies, and a strong desire for continuing education. They also seem to face a high prevalence of chronic noncommunicable diseases among the communities they serve. Improved training opportunities, selective additional medical equipment,

Acknowledgments

The authors would like to thank Tim Haffner, Vincent Vanderpool-Wallace, the Mayaguana Development Advisory Board, and the Ministry of Health of the Bahamas for their critical assistance with this study. We also sincerely thank the many health care providers, administrators, and community members for their selfless time in participating. Funding for this research was provided by the Mayaguana Development Advisory Board.

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This study received approval from the Institutional Review Board of Partners Healthcare (Boston, MA) and the Ethics Committee of the Ministry of Health of the Bahamas.

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