Diarrhoea among Children Aged under Five Years and Risk Factors in Informal Settlements: A Cross-Sectional Study in Cape Town, South Africa

ScHARR European Public Health student Thi Yen Chi Nguyen (Chi), published the following article in the International Journal of Environmental Research and Public Health (2021).

Int. J. Environ. Res. Public Health 202118(11), 6043; https://doi.org/10.3390/ijerph18116043

Previously trained in Public Health (BSc) and Epidemiology (MSc) at the University of Basel, Switzerland, Chi has 5 years of work experience in public health preventive programs, public engagement projects, and clinical research with underprivileged communities across low-middle income countries in Africa and Asia. Her main research interests are infectious diseases, antimicrobial resistance, and applied health data science. 

Chi's full profile can be seen in the article Vietnam's success story against COVID-19, also featured in the ejournal.

Authors and Affiliations

Thi Yen Chi Nguyen (1,2), Bamidele Oladapo Fagbayigbo (3,4), Guéladio Cissé (1,2), Nesre Redi (1,2), Samuel Fuhrimann (1,2), John Okedi (4), Christian Schindler (1,2), Martin Röösli (1,2), Neil Philip Armitage (4), Kirsty Carden (4),  and Mohamed Aqiel Dalvie (3,4)

Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, CH-4002 Basel, Switzerland
University of Basel, CH-4003 Basel, Switzerland
Centre for Environmental and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, South Africa
Future Water Institute, University of Cape Town, Cape Town 7700, South Africa


Background: There is limited data on the association between diarrhoea among children aged under five years (U5D) and water use, sanitation, hygiene, and socio-economics factors in low-income communities. The study investigated U5D and the associated risk factors in the Zeekoe catchment in Cape Town, South Africa. Methods: A cross-sectional study was conducted in 707 households in six informal settlements (IS) two formal settlements (FS) (March–June 2017). Results: Most IS households used public taps (74.4%) and shared toilets (93.0%), while FS households used piped water on premises (89.6%) and private toilets (98.3%). IS respondents had higher average hand-washing scores than those of FS (0.04 vs. −0.14, p = 0.02). The overall U5D prevalence was 15.3% (range: 8.6%–24.2%) and was higher in FS than in IS (21.2% vs. 13.4%, respectively, p = 0.01). Water storage >12 h was associated with increasing U5D (OR = 1.88, 95% CI 1.00–3.55, p = 0.05). Water treatment (OR = 0.57, 95%CI 0.34–0.97, p = 0.04), good hand-washing practices (OR = 0.59, 95%CI 0.42–0.82, p = 0.002) and Hepatitis A vaccination (OR = 0.51, 95%CI 0.28–0.9, p = 0.02) had significant preventing effects on U5D. Conclusions: The study highlights that good hygiene practice is a key intervention against U5D in informal settlements. The promotion of hand-washing, proper water storage, and hygienic breastfeeding is highly recommended.

Vietnam's success story against COVID-19

Thi Yen Chi Nguyen (called Chi in her language) is a current student (2021) in MPH European Public Health at ScHARR, under the Erasmus Mundus Excellent Scholarship. Previously trained in Public Health (BSc) and Epidemiology (MSc) at the University of Basel, Switzerland, Chi has five years of work experience in public health preventive programs, public engagement projects, and clinical research with underprivileged communities across low-middle income countries in Africa and Asia. 

Her main research interests are infectious diseases, antimicrobial resistance, and applied health data science.

With an enthusiasm for community development and the goal of developing into a global health expert, Chi’s current work has two foci. One is using an evidence-based approach to understand and mitigate the biological and behavioural risk of disease transmission. The other is on health technology, and how it can be utilized to provide accessible, affordable, cost-effective healthcare to all.

Outside of research activities, Chi is actively involved in several taskforces to promote voices and contributions of young public health professionals: SheffWHO 2020 as Theme Guide Director, Erasmus Mundus Association as Vietnam Country Representative, the Global Burden of Diseases Network as National Collaborator, and the Oxford COVID-19 Government Response Tracker as Data Contributor.

Chi, along with fellow European Public Health student Mashkur Abdulhamid Isa, has published work on Vietnam's COVID 19 response in the journal Public Health In Practice, https://doi.org/10.1016/j.puhip.2021.100132

Authors and affiliations

Chi Nguyen Thi Yen (a,b) Catherine Hermoso (c), Elaine May Laguilles (c), Louise Elaine De Castro (c), Shera Marie Camposano (c) Noel Jalmasco (c), Kim Aira Cua (c), Mashkur Abdulhami Isa (b), Edikan Friday Akpan (d), Tuan Phong Ly (e), Shyam Sundar Budhathoki (f), Attaullah Ahmadi (g,h), Don Eliseo Lucero-Prisno III (i,j)

a Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box, CH-4002, Basel, Switzerland
b School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
c College of Medicine, Bicol University, Daraga, Albay, Philippines
d Faculty of Pharmaceutical Science, University of Port Harcourt, Port Harcourt, Nigeria
e School of Tourism Management, Macao Institute for Tourism Studies, Macao, SAR, China
f Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
g Medical Research Center, Kateb University, Kabul, Afghanistan
h Global Health Focus Asia, Kabul, Afghanistan
i Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
j Faculty of Management and Development Studies, University of the Philippines (Open University), Los Baños, Laguna, Philippines


Vietnam's close proximity to China where the COVID-19 outbreak started made it one of the countries expected to have widespread transmission of the virus. However, the country opposed this expectation and attained low spread of COVID-19 infection due to its proactive approaches in containing the disease. As of March 11, 2021, Vietnam has a total of 2529 confirmed cases, equivalent to 26 cases per one million population-compared to the global rate of 15,223 cases. The low-cost model approach used by Vietnam in dealing with previous public health issues, tackle the importance of a strategic public health system, good governance, and citizen cooperation in the fight against COVID 19 pandemic. This paper aims to analyze Vietnam's achievement in its early and continued success in combating COVID-19 by taking into account various aspects of its health system and experience on outbreaks that have previously occurred and how these can be applied to current COVID-19 responses.

Levels of Physical Activity, Patterns, and Perceived Barriers, Among University Students in Oman: A cross-Sectional Study

Amal Al Siyabi graduated as a medical doctor from Sultan Qaboos University (2007) and is now a specialist in Public Health, having graduated from the ScHARR MPH in 2020. Amal currently works as the head of Community and Health Partnership in the Ministry of Health, Oman. She focuses on healthy cities and  villages, and physical activity as a focal point in Oman. She is also a member of the national committee of narcotic drugs and psychotropic substances prevention.

Her Masters' dissertation project looked at the patterns of physical activity and perceived barriers to physical activity among University students in Oman, drawing on networks of students and using snowball sampling methods to achieve high levels of coverage of her target population. She was supervised by Dr Hannah Jordan.

Amal went on to publish her findings in the International Journal of Science and Economics.


Amal Al Siyabi, Ozayr Mahomed, Huda Al Siyabi, Sitwat Usman Langrial, Salah T. Al Awaidy


Objective: To investigate the prevalence, pattern, and the perceived barriers, of physical activity among Omani university students studying in Oman.

Methodology: A self-administered questionnaire using the short-form of the International Physical Activity Questionnaire (IPAQ) was disseminated to a selected sample of university students, from their second academic year onwards through Whats AppTM. Descriptive, Bivariate and multivariate analysis was conducted to measure patterns, levels and associated factors.

Results: Overall 44% were classified as highly active, 30% as moderately active, and 26% as lowly active or inactive. Younger students (< 22 years), male students, respondents with a positive perception of weight (normal or below), and self-perceived physically active (moderate to high) were more likely to engage in moderate to high physical activity. Students in university for < 4 years (OR: 2.69) and students were members of sports youth clubs (OR: 2.76) were significantly more likely to engage in moderate or high physical activity. Lack of motivation was the top barrier of physical activity.

Conclusions: More than a quarter of surveyed Omani university students were physically inactive which has the potential to have a detrimental effect on their health and well-being. Therefore, creating a conducive environment is essential for improving short and long-term health outcomes.

SheffWHO 2019: Winning Position Paper: NONCOMMUNICABLE DISEASES

Building on the hugely successful 2018 debut, SheffWHO explored the theme “Non-Communicable Diseases: A Crisis in Slow Motion” from 8-10 March 2019. As before, delegates represented WHO Member States, as well as Non-Governmental Organizations (NGOs), pharmaceutical companies and the media.

Contributing to interdisciplinary and experiential learning in global health, delegates from all disciplines (not just science/health) were encouraged to participate in this event. They discussed, co-operated, and negotiated with other stakeholders to produce resolution papers addressing the simulation theme, as an important global health priority.

The winning position paper was by Jowi Kryz Guillen.

For the SheffWHO 2019 simulation, Jowi was tasked to prepare a position paper for Pakistan as a delegate of the Eastern Mediterranean Regional Office (EMRO). This position paper addressed the conference theme of Non-Communicable Diseases (NDCs), which included details of mortality and morbidity due to NCDs and potential causal factors, such as diet, air quality and lifestyle. The main goal of the position paper was to propose alternative solutions to overcome prevalent NCDs in Pakistan, which are cost-effective and right-impact interventions that respects the political and cultural factors unique to Pakistan. Furthermore, the recommended actions enhances present healthcare platforms and complements the WHO agenda for combatting NCDs.

Jowi has just finished her MSc in Biomaterial and Regenerative Medicine at the University of Sheffield, where she is expected to graduate this January 2020 with distinction. She is currently taking a sabbatical and volunteering with the British Council (Generation UK - InternChina) in Chengdu, to teach English and work for a local orphanage. Her next goal is to start a PGCE in Biology/Chemistry at University College London in 2020.

Name: Jowi Kryz Guillen
Role: Member State Representative of Pakistan
Region: Eastern Mediterranean (EMRO)
Twitter: @jowikryz

Noncommunicable Diseases 

National Position Paper Pakistan

Pakistan has been named to be the 6th most populated country in the world, with over 200 million inhabitants contributing to 2.65% of the total world population
1. Noncommunicable diseases, NCDs, and their shared risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity, as well as air pollution) represent an unacceptable blind spot in our collective path to sustainable development, causing far more deaths and disability than any other group of diseases2. NCDs and injuries are amongst the top ten causes of mortality and morbidity in Pakistan3; estimates indicate that they account for approximately 25% of the total deaths within the country4. NCDs contribute significantly to the premature mortality and morbidity, and impose a heavy economic burden on individuals, societies and health system5. In most cases, it is the economically productive workforce (age 30 to 70 years old), which bears the brunt of these diseases3,4,5.

NCDs currently share over a fifth of the disease burden in Pakistan, and 2.5% are disabled. The majority of such mortalities were caused by the four main NCDs, namely: cardiovascular disease, CVD (44% of all NCD deaths); cancer (22%); chronic respiratory disease (9%); and diabetes. Over the past 5 years, the proportion of underweight women has decreased (14% to 9%)
6, yet the proportion of overweight or obesity women has increased by 12%6, where the rates are significantly higher than men, regardless of residence7. The coexistence of underweight in early life with obesity in adults presages both a higher prevalence and incidence for NCDs such as CVD and diabetes. Existing population-based morbidity data on NCDs in Pakistan show that 1 in 3 adult, over the age of 45 years, suffers from high blood pressure6, and the prevalence of diabetes is reported at 10%. The major contributing factors to these diseases are the combination of increasing urbanisation, changing lifestyles, reduced physical activity and higher energy density of diets with Pakistani cooking.

Pakistan is the only country to have been created in the name of Islam, therefore tobacco use and alcohol consumption would innately be at low incidences (0.3 litre consumption per capita and 36.7 prevalence of tobacco smoking; persons aged 15 and older),
8 relative to other countries. However in 2016, the environmental issue of air pollution became apparent, where the mortality rate attributed to household and ambient air pollution was at 173.6 (per 100 000 population), inflicting 3.8 million deaths from chronic respiratory disease and 9.0 million deaths from cancer.8 Yet again women are at greater risk of suffering from cancer, namely ovarian and breast cancer, taking the lives of 40 000 women per year9,10. According to multiple studies, breast cancer occurs to 1 in every 9 Pakistani woman, which is one of highest incidence rates in Asia10 and is not sparing even the younger age groups 9,10.

Despite the magnitude of the threat posed by NCDs, the current health expenditure (CHE) of Pakistan is 2.7% (GDP, 2015; US $38 per capita); the total expenditure on health is US $18 per head
10. The World Health Organisation (WHO) has criticized the country’s reluctant investment (inadequate by 0.4%, according to United Nations human development index) towards health11, and recommended the allocation of US $34 per head to fund a package of essential health service8. Furthermore, Pakistan was notoriously condemned for the vaccine-preventable diseases that caused half of all the deaths in 2008, based on the ‘Western sterilisation plot’12. Thereafter, Pakistan became the first country in the WHO Eastern Mediterranean Region to conduct joint external evaluation in 2016, impetus to the tripartite alliance between the Ministry of Health, Government of Pakistan, the WHO, Pakistan office and the NGO Heartfile13. A national action plan for the International Health Regulation (IHR) Global Health Security Agenda was developed, with the aim to fulfil the IHR requirements to prevent, detect and mound a comprehensive public health response to health threats.

Addressing NCDs in developing country such as Pakistan is a multidimensional challenge with implication at different levels that requires the implementation of cost-effective and right-impact interventions. These include institutional, community and public policy levels changes set within a long-term and life-course perspective. Therefore in congruent to the WHO Global Coordination Mechanism (GCM) for the prevention and control of NCDs, the following actions could aid Pakistan to fight against NCDs and, promote mental health and well-being:  

1. Government to prioritise prevention and treatment of NCDs for the 
next expenditure
  • Increase the CHE % GDP and total expenditure on heath per person
  • Establish a mandate to identify key stakeholders and experts in policy making, assess the existing status of NCDs, prepare a policy document and provide recommendations in response to NCDs
2. Strengthen knowledge and evidence via surveillance and research 
  •  Enhance the monitoring systems in rural areas, to identify the gaps in health care, reduce unreported cases and obtain reliable epidemiology of diseases
  • Allocate domestic resources towards peer-review literature research on health, nutrition, education and disease progression 
3. Implement awareness and improve understand of NCDs 
  • Train doctors and community health workers to use techniques under the WHO guidelines for diagnosing diseases
  • Rational use of drugs to prevent the overuse of antibiotics and curb microbial resistance
  • Reduced inequality to healthcare delivery between private and public sectors 
4. Government to prioritise education for the next expenditure
  • Full and universal access to health programmes and actions to tackle physical inactivity and promote mental health 
  • Funded education and access to higher learning for healthcare professions to increase the rate of doctor-to-population ratio 
5. Exploit digital healthcare platforms and existing partnerships
  • Efficient service delivery to locating appropriate healthcare information, booking appointment with doctors and ordering the correct medication 
  • Maintain transparent communication and collaboration between government, NGO, manufactures, general public and private sector
  1. Department of Economic and Social Affairs, Population Division: Pakistan Population (LIVE) [Internet]. World Population Prospects: 2019 [cited 2019 Mar 5]. Available from: http://www.worldometers.info/world-population/pakistan-population/ 
  2. Schweizerische Eidgenossenschaft. General Meeting of the WHO Global Coordination Mechanism for the prevention and control of noncommunicable diseases (GCM/NCD). Co-chairs Statement. Geneva, Switzerland: Swiss Confederation, 2018. 
  3. Hyder AA, Morrow RH. Lost Healthy Life Years in Pakistan in 1990. Am J Public Health 2000;90(8):1235–40. 
  4. Federal Bureau of Statistics, Statistics Division. Pakistan Demographic Survey 2001. Islamabad, Pakistan: Government of Pakistan, 2003. [cited 2019 Mar 5]. Available from: http://www.pbs.gov.pk/content/pakistan-demographic-survey-2001
  5. World Health Organization. World Health Report 2000 - Health Systems: Improving Performance. Geneva, Switzerland: WHO, 2000.
  6. National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2019. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF. 
  7. Nanan DJ. The obesity pandemic – Implications for Pakistan. J Pakistan Med Assoc. 2002 Aug; 58(8). 
  8. World Health Statistics 2018: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: WHO; 2018. 
  9. Jardoon Z, Shah SP, Bourne R, Dineen B, Khan MA, Gilbert CE, Foster A, Khan MD. Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey. Br J Opthalmol. 2007 Oct 9; 91(10): 1269–73. [Online, cited 2019 Mar 5] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001008/ 
  10. World Health Organization – Cancer Country Profiles. Pakistan: World Health Organization, 2014. 
  11. WHO Global Health Expenditure Atlas: September 2014. Switzerland: World Health Organization; 2014. 
  12. Janjua H. Afghan clerics in talks with Isis to break polio vaccine myths. The Guardian, Global Health, 2018, Mar 27 
  13. National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan. Islamabad, Pakistan: tripartite collaboration of the Ministry of Health, Government of Pakistan; WHO, Pakistan office, and Heartfile; 2004.


The first of its kind in Sheffield, SheffWHO explored the theme “Outbreaks and Pandemics: Addressing the Next Crisis” from April 27th-29th, 2018. Delegates represented WHO Member States, as well as Non-Governmental Organizations (NGOs), pharmaceutical companies and the media.

Contributing to interdisciplinary and experiential learning in global health, delegates from all disciplines (not just science/health) were encouraged to participate in this event. They discussed, co-operated, and negotiated with other stakeholders to produce resolution papers addressing the simulation theme, as an important global health priority.

The winning position paper, competing with 70 attendees, was by Dr Shukrat O. Salisu-Olatunji. Shukrat completed her Masters in Clinical Research in ScHARR in 2017.

Delegate name: Dr Shukrat O. Salisu-Olatunji 

Region: AFRO (Country: Nigeria) 

Role: Member state delegate 

Twitter handle: @jumisal25 


Nigeria is known as the most populous nation in Africa with an estimated population of 196 million in April 2018 and a population growth rate of 2.67%[1]. With globalization, international trade and travel across borders, Nigeria is vulnerable to epidemics and outbreaks of infectious diseases from within and without. It is therefore critical to ensure optimal preparedness and response to this global threat and to empower the health system and its stakeholders appropriately with the goal of preventing pandemics and minimising casualties from such occurrences.
Health funding is key in achieving optimal preparedness and response to outbreaks and epidemics, and Nigeria’s health allocation of 4.17% of its annual spending in 2017 is a far cry from the WHO recommendation of 13% [2,3]. The effects of poor health funding are felt across the three tiers of health care and most especially in primary care which is the foundation of health delivery closest to the people. The majority of patients (71.7%) must pay for health care out-of-pocket at the point of service even as the country puts in efforts to achieve Universal Health Coverage. There is high reliance on foreign aid and NGOs as a source of funding for public health initiatives like childhood immunization, HIV treatment, TB treatment among others.


In recent times, Nigeria has experienced outbreaks of public health importance, including the Ebola outbreak in 2014. The strength of local response and collaborations between levels of government greatly influences the outcomes of such outbreaks with respect to acute response and control measures put in place to manage the situation. With the Ebola outbreak which involved several West African countries, the response was highly commendable as Nigeria succeeded in controlling the outbreak within three months and was declared Ebola free by the WHO[4]. The success of the country’s response has been attributed to the Incident management/ Emergency Operation Centre approach which facilitated resource and fund mobilization and coordination of response involving government health facilities, international aid organizations, NGOs and the private sector[5]. This success has however not been replicated with other outbreaks like Lassa fever, cerebrospinal meningitis, cholera and yellow fever which persist in the country. In the country’s experiences, the importance of strengthening health system’s preparedness in terms of personnel, co-ordination of stakeholders and mobilization of resources, provision of needed medications, vaccines and consumables and education of the populace has stood out.


The health system’s preparedness and response to outbreaks is dependent on coordination of multiple stakeholders and the public. Poor political commitment especially with regards to funding, weak primary health care system, lack of ownership and community involvement are some of the challenges which negatively impact on outbreak/epidemic response. Political crisis and instability especially in Northern Nigeria also further reduce access to healthcare and jeopardises the chances of effective response to an outbreak. Distrust of the authorities and stigma associated with some communicable diseases like Lassa fever, as well as lack of funds to pay for healthcare services may discourage early reporting and identification of cases, thus increasing the likelihood of spread and epidemic potential of such a condition.


  • Strengthen the foundation of the healthcare system by improving primary health care. Focus on disease prevention, health promotion and notifiable disease surveillance would provide a better defence against outbreaks at all levels of health care. Public health personnel must be aware of minimum standard operating procedures for potential epidemic prone diseases; e.g. case identification, contact tracing and isolation where required. 
  • Create regional laboratories to facilitate rapid diagnosis and enhance surveillance and tracking of outbreaks. 
  • Empower, educate and inform the populace through an effective communication system that enables early identification and reporting of suspected cases at times of outbreaks and minimises anxiety, stigma and harmful practices in the event of an outbreak. 
  • Train healthcare personnel to enhance case management and optimal infection prevention and control in health facilities and the community. 
  • Build capacity of Disease Surveillance and Notification Officers in each state. Strengthen Local governments in training DSNOs to use IDSR guidelines and facilitate timely reporting. 
  • Engage private sector in a focused and coordinated manner. 
  • Key into global initiatives for outbreak control like the recently launched “Eliminate Yellow fever in Africa by 2026”. 


Policies and interventions to build capacity of personnel, mobilise funds and needed resources and establish a preparedness and response strategy are essential in addressing the threats of outbreaks/epidemics. Improvements in the health system achieved through foreign aid and support must be sustained to empower the healthcare system at primary, secondary and tertiary levels.


  1. Country meters. Live Nigeria population (2018). Current population of Nigeria — Countrymeters [Internet]. 2018 [cited 2018 Apr 17]. Available from: http://countrymeters.info/en/Nigeria/ 
  2. World Health Organization. WHO | Nigeria [Internet]. WHO. World Health Organization; 2018 [cited 2018 Apr 22]. Available from: http://www.who.int/countries/nga/en/ 
  3. Nigeria’s Grossly Inadequate 2017 Health Budget [Internet]. THIS DAY. 2017 [cited 2018 Apr 22]. Available from: https://www.thisdaylive.com/index.php/2017/02/09/nigerias-grosslyinadequate-2017-health-budget/ 
  4. Centers for Disease Control and Prevention. Ebola Virus Disease Outbreak — Nigeria, July– September 2014 [Internet]. Morbidity and Mortality Weekly Report. 2014 [cited 2018 Apr 22]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm 
  5. Courage KH. How Did Nigeria Quash Its Ebola Outbreak So Quickly? - Scientific American [Internet]. Scientific American. 2014 [cited 2018 Apr 22]. Available from: https://www.scientificamerican.com/article/how-did-nigeria-quash-its-ebola-outbreak-soquickly/

Why A&E? A study into patient factors in low-acuity attendance in an urban district general hospital

Seth White graduated from ScHARR MSc in Clinical Research in 2016. His Masters' dissertation project was supported by Rotherham Emergency Department, and looked into reasons underlying increasing demand on the Emergency Department, particularly for less severe and urgent health problems.

In collaboration with his supervisor Jo Coster, and Jeremy Reynard from Rotherham District General Hospital, Seth's research adresses problems facing Emergency Departments throughout the UK and beyond.

Authors and Affiliations

Seth White MB ChB 1,3; Joanne Coster BSc 1; Jeremy Reynard MBBS FCEM 2

1 School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA
2 Emergency Department, Rotherham District General Hospital, Rotherham, S60 2UD
3 Corresponding author: seth.t.white@gmail.com, MD Anderson Cancer Center, 1515 Holcombe, Houston TX, USA 77030, T: +17137455253

KEYWORDS: Emergency demand, qualitative, interview study, non-urgent attenders, inappropriate attenders, ambulatory attendance, Accident and Emergency, managing demand


Introduction: A&E demand is rising inexorably across developed countries. Demographic factors and population health do not fully account for this rapid rise. Considerable demand comes from relatively low-urgency patients, who are likely to be discharged without investigation or treatment. Understanding why such patients choose A&E is important when configuring current and future services.

Methods: Semi-structured interviews undertaken at a local district A&E department situated in an urban deprived area. We included A&E attenders triaged to category 4 or 5 on the Manchester Triage Scale that did not present with an acute traumatic injury or were identified as vulnerable. Transcripts were analysed using framework analysis.

Results: Fifteen patients were recruited and all were interviewed. None described their health problem as an emergency. Patients responded along three main themes. 1) Access to and confidence in primary care; participants lacked confidence in their GP and had difficulty getting appointments. There was a belief that GP consultations were futile as they would inevitably be referred to A&E. 2) Pull factors to A&E; relates to how perceptions of need and positive views of A&E (availability of facilities for investigation, speed and perceived quality) influence health seeking behaviour. 3) Individual and external factors; many patients were referred to A&E and NHS 111 was a common source of referral. Individual factors mostly related to anxiety and pain or using A&E as an informed decision.

Conclusion: These findings demonstrate that patients will select A&E in lieu of other available options due to perceived benefits of A&E care and perceived barriers and limitations to primary care. Previous health care experiences (positive and negative) have a strong influence on future health care choices. The NHS 111 number appears to routinely refer low-urgency patients to A&E and this warrants further investigation.

What this paper adds
What is already known on this subject:
A&E demand is rising rapidly.  Some of this demand is from patients who may not require emergency or urgent care. Why such patients choose A&E is unclear.
What this paper adds:
Patients attend A&E because they believe it is a superior service with better access to investigations, better clinicians and greater ease of access.  These patients are unlikely to choose primary care if given the option.  This has implications for service planning.


Rising demand for Accident and Emergency (A&E) care is a well-known and much politicized issue.  Demand has risen 32% over the past ten years alone [1] and is a common problem across developed countries.[2]  The factors driving this increase are not fully understood – population increase and ageing alone do not account for the magnitude of rises seen.  Several interrelated factors have been  suggested to explain this increase; increasingly litigation-averse practices, organizational changes within healthcare systems and increased community expectations are often cited.[3]   

One significant factor, which may be difficult to assess, is a shift in patient behavior.  There is a view that an increasing number of patients bypass primary care and attend A&E ‘inappropriately’.[4]  Many studies have assessed the ‘appropriateness’ of patient attendance in A&E, asking whether patients may have been more appropriately treated elsewhere.  Such studies (using the judgement of physicians) have estimated various inappropriate or avoidable attendance rates of between 6-80%.[5] 

The concept itself is poorly defined in the literature, with individual studies often using independently crafted definitions with little agreement between emergency physicians themselves.[6]  Although the term “inappropriate attender” is difficult to systematically operationalise and may be unhelpful, it is clear that a significant subpopulation present with low-acuity problems to A&E departments.  Such patients may contribute to overcrowding and increase strain on health services.[3]  Attempts to divert such patients to other urgent or immediate healthcare services , such as walk-in centers or other services, have not been shown to reduce A&E demand or influence patients’ health seeking behaviour.[4 7]

This research was therefore undertaken to identify and understand motivating factors in health care decision making for low-acuity patients who choose to attend A&E.  We sought to explore the underlying reasons behind patient decision making and how previous health care experiences and patient views of health services impact and shape future decision making. 



The research was undertaken at Rotherham District General A&E department located in England.   This A&E department serves the local area of Rotherham (population: 257,000), which is a relatively ethnically homogenous area [8] with a high index of social deprivation, being ranked in the bottom quintile of local authorities nationally.[9]  The A&E department is currently undergoing refurbishment with plans to integrate a primary care service with the emergency department to form the ‘Emergency Centre’,[10] expected to be completed in 2017.

Participant Selection

Ambulatory adult patients who were triaged to category four or five on the Manchester Triage Scale (the two lowest acuities) were eligible for the study.  Patients with recent onset of trauma (<24 hours), were in vulnerable patient groups or acutely distressed were excluded from the study.  These criteria were designed to capture a less urgent population able to participate in an interview who could feasibly have accessed treatment elsewhere.  Formal prospective assessment of suitability was not made as this was felt to be too subjective to be useful.  Ethical approval was gained from Leicester Central research ethics committee, and study site approval was obtained from NHS Rotherham and HRA prior to the commencement of the study (REC reference: 16/EM/0205).

Exclusion Criteria

-          Pregnancy
-          Acutely distressed
-          Mental health issue
-          Trauma (if <24hrs or injury visible)
-          Formal referral (with letter)
-          Inadequate English
-          Cognitive impairment

Data Collection

All data and information was collected within the A&E department. Patients were screened during triage by the triage nurse, who held a copy of the study eligibility criteria.  Potential participants were then identified to the principle investigator, and were provided with participant information. After having time to read the information, participants were given the opportunity to participate and if they consented, were invited to a quiet side room where consent was taken in writing.  Interviews were semi-structured in nature and recorded on digital Dictaphone.  A topic guide was used to inform the interview and this was further developed and added to as the research progressed.  Initial topics were derived from previous research in the UK and abroad and included a brief chronology of events, perceptions of A&E and primary healthcare services, past experiences and perceived health needs for this care problem.  

A second stage exclusion criteria was applied as recruitment only occurred when the wait between triage and being seen was at least one hour, so as not to delay care to participants.  The study was restricted to regular office hours (9-5 Mon-Fri) to avoid factors around out-of-hours access, as the study was primary concerned with patients who could feasibly have chosen to attend a primary care service.  Interviews were carried out during summer 2016.


Interviews were transcribed verbatim by the lead researcher (SW). Transcripts were analyzed within NVIVO 11 software [11] using the method of framework analysis, which involves a series of clearly defined, systematic and sequential steps.[12]  Following familiarization with the interview transcripts, initial themes were coded around basic concepts from interview responses such as “anxiety” or “perceived clinician quality” to develop a working analytic framework.  These were then discussed and revised with a second researcher (JC) and applied to subsequent interview transcripts.  Revisions were undertaken over several meetings.  Continuing the same process, interview data was gradually interpreted and collated into three superordinate themes: “access to and confidence in primary care”, “pull factors to A&E”, and a third, looser superordinate theme “individual and external factors”. 


Participant characteristics

Fifteen participants were recruited; participants ranged in age from 18 to 63 and included seven women and eight men with a broad variety of presenting complaints (see Table 1). Six participants gave home addresses outside of the catchment area of Rotherham A&E. Disposal outcome was only available for thirteen participants – one participant’s outcomes could not be traced and another was recorded only as ‘seen by GP’. Four participants brought a relative into the interview (no carers were interviewed) but only three contributed to the interviews.

Out of the thirteen participants with disposal outcomes available, five received advice only, and three received advice and a prescription. Only one participant received a specialty referral and no participants were admitted. One participant did not wait to be seen by a clinician after the interview. Two received wound care in the department, both judged to be candidates for wound care in general practice by the researcher. Participants came from a geographically diverse area and nearly all participants resided in areas with high levels of deprivation. Six participants had home addresses listed with an A&E in closer geographical proximity (although location of incident/onset of illness was not recorded). Three participants reported travelling to Rotherham in preference of another A&E during the interview (with one being advised to go to specifically Rotherham via 111 due to presence of maxillofacial surgeons – though they were not seen by the maxillofacial surgeons).

Table 1 - participant characteristics

Deprivation quintile
Closest ED
Growth on nose
Seen by GP
R leg problem
Mexborough (MIC)
L side numbness
Advice, prescription
Injury to R foot
Dressing, local anaesthetic, advice
Pain L knee
Prescription, advice
Dental problem
Prescription, advice
Knee prob
Outcome unavailable

Left leg pain
Did not wait

R foot injury
R leg injury
Left knee injury
Observation, specialty referral, advice
Mexborough (MIC)
Groin pain
Observation, advice
R foot wound prob
Wound cleaning, advice
RTC/neck pain
R wrist injury

MIC = minor injury centre. Closest ED – closest emergency department or nurse led minor injuries unit (walk-in centres not included).  DQ = deprivation quintile

Thematic analysis

After applying several revisions to the coding structure, a definitive thematic framework emerged describing the factors behind A&E attendance.  Twenty-one individual subthemes were identified during the initial coding and many of these were closely related or interlinked. All respondents contributed to at least one main theme and often more. Three overarching themes were identified and each contained subthemes: access to and confidence in primary care, pull factors to A&E, and individual and external factors.

Bypassing Primary Care

Access to and confidence in primary care related very closely to pull factors to A&E. A&E was almost universally better regarded than primary care, even in participants who voiced positive opinions of their general practitioner.  Many participants dismissed the idea of attending primary care as ‘futile’ and were attracted to A&E as able to provide more definitive care.  Many participants also believed that if they attended their GP it was merely delaying the inevitable A&E attendance and referred to ‘cutting out the middle man’ when describing their reasoning behind this.
“Just because it was something that I didn’t know what it was, I thought I’d cut the middle man out and go straight to A&E” Participant 2
“I just thought that I'd just cut the middle man out by coming here for X-ray because I thought I would need one”Participant 5
"Whenever I've gone to the walk in or phoned 111 they tell me A&E straight away, or that you need to be seen within the next 4 hours…….so now when I get the pains I jump in a taxi and I come here.”Participant 3
“It’s just that every time we’ve been to see the GP it’s that they’ve more or less told him that they don’t specialize in that kind of thing so we go to A&E and you’ll get better treatment.”Participant 1
This closely related to three subthemes: 1) Perceived need for diagnostic equipment, 2) Difficulty in accessing timely primary care, and 3) Lack of confidence in primary care.
Perceived need for diagnostic services was an important factor in many decisions and a very prominent theme throughout the interviews.  Radiographs were commonly thought to be required.  No other specific investigations were listed. 
“So I was going to ring the doctor and then I thought they might have to do an x-ray so I thought I’d come here and get it checked out as soon as possible” Participant 9
“I just thought that by coming here I'd get an X-ray” Participant 5
Difficulty in accessing the general practitioner was also very common theme in the research – some participants spoke of long waits, and first-come-first-serve telephone appointments as barriers to GP attendance.  It is worth noting that this was still a prominent theme despite all the research being conducted during normal weekday working hours.
“The thing is that it’s really hard to get an appointment with them they’ve got a system where you need to ring at bang on eight in the morning and it’s either one or half one in the afternoon to get an afternoon appointment. But if you try to ring at eight… I’ve had it before where I’ve tried to get an appointment and it’s three [minutes] past eight and they’ve all gone” Participant 11

Confidence in general practice was mixed overall, with several participants speaking of previous issues or disagreements that led them to seek alternate care in A&E.
“I’ll tell you when I got there I couldn’t breathe, I’ve got COPD, and the thing he said to me that the best thing to do was to go up to the moors, park car, and take a few deep breaths. And that night, ended up in hospital with a blood clot on the lung and pneumonia. That’s how good he [GP] were.”Participant 1

Although opinions of GP ability were mixed, there was generally a greater confidence in emergency physicians.
“I do like hospital because of all the equipment they have, everything right here. But when you come here it's like they know what they're doing more than other places” – Participant 4

Choice and External Influences on Agency

Individual and external factors is a looser association of themes. This represents factors in the more immediate decision making process. Anxiety and perceived severity of illness was cited by several participants, and was an expected finding based on previous research.  It was however, less prominent than expected.  Some patients expressed uncertainty. 
“I’m a little bit worried – do I need seeing to straight away?” Participant 2

“Well I’m not quite sure… I don’t know 100% whether or not I should be in A&E. I don’t know if I qualify to be in A&E with my injury. Well I don’t know it’s not really an emergency. It is an accident though! But not an emergency. So I don’t know whether it was right to come to A&E” Participant 13
A number had been referred to go to A&E by 111 and a similar number by friends, colleagues or informally by other medical professionals. Interestingly a small but significant minority made an informed choice based on convenience related factors, resulting in travelling not insignificant distances past other A&E departments to reach their preferred A&E department.
“Well yeah, I do actually live in Sheffield. I don't like the northern general it's always too busy… and it's a nightmare parking at the northern general isn't it?” Participant 7
One participant stated that Rotherham A&E was their usual place of medical care. Participants were aware of pressure on A&E departments and often had relatively detailed knowledge of locally available services.


Implications for service delivery

This research builds on previous research into patient decision-making in seeking A&E care and explores why patients in a deprived population setting attend A&E in lieu of other health care services for low urgency problems in-hours.  Patients were unanimous in their perception that A&E is the best place to attend for ease of access and availability of diagnostic equipment.  Patients perceived A&E as a more ‘definitive’ option for care, implying that general practice was unable to decisively attend to their complaints.  This relates to the concept of convenience, which has strongly occurred throughout the literature.[3 13]  What was distinct in this research was the concept of futility associated with GP attendance; many patients believed that they would have ultimately been referred to hospital to either A&E or for investigations available in A&E.  

Anxiety and perceived severity were less frequent complaints than expected; participants did not believe their problems were emergencies.  External sources of advice appear to have played a part; some patients cited discussions with healthcare professionals informally, or the 111 service.
It is clear from the responses within the study that A&E attendance in low-urgency patients is largely a logical and considered choice, as it meets their perceived health needs with convenience.  Although reasons for attending A&E varied between participants, it was evident that most respondents had considered their options before attending.  

In this sense A&E may be perceived to be ‘a victim of its own success’.[14]  Confidence and positive perceptions of the service may be increasing footfall through the service and inadvertently decreasing use of other, more conventional means of non-urgent healthcare for reasons that go beyond simple indecision/anxiety and access issues.  Public satisfaction with General Practice, although high, has been on a downward trend for several years.[15]  It is possible that changing perceptions between services are playing a role in demand. 

Given that, from a patient perspective, A&E is a logical and convenient choice, the very concept of “appropriateness” around attendance is unhelpful  as it suggests patients are expected to make a decision on their care which physicians themselves sometimes find difficult to explain, as discussed previously.[6]  Furthermore, the very logic of approaching the problem as one of “appropriateness” is fundamentally flawed.  It is unreasonable to place the burden of decision of choice on patients with no medical expertise and can lead to inequity within the healthcare system.  Such opinions have been raised before,[14] emphasizing the need for a patient-centered approach to health service design.

This research also helps explain why the extension of primary care options has not demonstrably impacted demand.[7]  Availability of primary care may have some influence, but a majority appear to be deliberately seeking A&E care for the clear benefits it brings.  

The role of 111 in referring patients unnecessarily may need to be investigated further as 111 was a common source of referral of low urgency patients to A&E.  As 111 was introduced to provide advice to self-care and encourage alternatives to A&E, this is a counterproductive outcome.  This is consistent with available evidence which does not demonstrate any reduction in A&E demand with 111 rollout.[16]  

As many A&E departments integrate primary care services into emergency departments this research demonstrates the logic of this, from a patient perspective.  A unified triage service between primary and emergency services may be necessary as patients may, for various reasons, select emergency care in preference if offered a choice.  Future research into the integration of primary care and emergency care services and research exploring the organizational responsibilities and remit of each service within a shared system is required.


Though the study appears to have captured a largely low-urgency group of patients, it is not certain how generalizable these answers may be to the broader population.  Certain populations, specifically vulnerable groups such as pregnant women and children, were excluded on ethical grounds and may have important differences in their presentation factors which were not assessed here.  Children may be an especially important source of low-urgency demand, as has been suggested by others.[17]  Furthermore, this is a single-centre study and the population captured here may not be generalizable to the wider population, given the particular demographic features of this setting.

Finally, the findings must be interpreted in the context where they were taken.  The principle investigator is a physician who has previously worked in the department.  Participants were made aware of this fact and may have spoken of A&E in a more positive light than they would have otherwise.  The authority of the investigator may also have placed additional pressure on participants to give socially desirable answers.


Low urgency patients often choose A&E due to perceived benefits in clinician quality, access and available diagnostic equipment as well as other external influences and patient factors.  Such patients may actively be choosing to come to A&E for its perceived benefits and may not be dissuaded by the offer of parallel services.  This research supports the logic of shared triage in the context of a joint primary care-emergency service.  The research also implies difficulty in applying the Keogh report, as low urgency patients may be less likely to seek care outside of an A&E setting. 


This study has received no funding and was undertaken in the context of a master’s dissertation by Seth White supervised by Jo Coster at the University of Sheffield.  There are no conflicts of interest.


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