title: A structured assessment of emergency and acute care providers in Afghanistan during the current conflict.
abstract: BACKGROUND
  Afghanistan has struggled with several decades of well-documented conflict, increasing the importance of providing emergency services to its citizens. However, little is known about the country's capacity to provide such care.
  
  
  METHODS
  Three native-speaking Afghan-American physicians performed an assessment of emergency care via combined quantitative and qualitative survey tools. Hospitals in Kabul, Afghanistan were selected based on probability proportional to size methodology, in which size was derived from prior work in the country and permission granted by the administering agency and the Ministry of Health. A written survey was given to physicians and nurses, followed by structured focus groups, and multiple days of observation per facility. A descriptive analysis was performed and data analyzed through a combination of variables in eight overarching categories relevant to emergency care.
  
  
  RESULTS
  One hundred twenty-five surveys were completed from 9 hospitals. One third of respondents (32.8 %) worked full time in the emergency departments, with another 28.8 % working there at least three quarters of the time. Over 63 % of providers believed that the greatest delay for care in emergencies was in the prehospital setting. Differences were noted among the various types of facilities when looking at specific components of emergency care such as skill level of workers, frequencies of assaults in the hospitals, and other domains of service provision. Sum of squares between the different facility types were highest for areas of skill (SS = 210.3; p = .001), confidence in the system (SS = 156.5; p < .005), assault (SS = 487.6; p < .005), and feeling safe in the emergency departments (SS = 193.1, p < .005). Confidence negatively correlated to frequency of assaults (Pearson r = -.33; p < .005) but positively correlated with feeling safe (Pearson r = .51; p < .005) and reliability of equipment (Pearson r = .48; p < .005). The only correlation for access to services was prehospital care (Pearson r = .72, p < .005).
  
  
  CONCLUSIONS
  There is a significant need to provide emergency care services in Afghanistan, specifically prehospital care. High variability exists among facility-type in various components of emergency services provision.
authors.affiliation: Mclaren Regional Medical Center Department of Family Medicine, Michigan State University College of Human Medicine, 401 South Ballenger Highway, Flint, MI 48532 USA.
authors.forename: Leeda
authors.initials: L
authors.lastname: Rashid
authors.affiliation: Harbor-UCLA Medical Center, Division of Emergency Medicine, 1000 West Carson Street, Torrance, California 90509 USA.
authors.forename: Edris
authors.initials: E
authors.lastname: Afzali
authors.affiliation: Department of Emergency Medicine, Michigan State University/Synergy Medical Education Alliance, 1000 Houghton Ave, Saginaw, MI 48602 USA.
authors.forename: Ross
authors.initials: R
authors.lastname: Donaldson
authors.affiliation: Mclaren Regional Medical Center Department of Family Medicine, Michigan State University College of Human Medicine, 401 South Ballenger Highway, Flint, MI 48532 USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Lazar
authors.affiliation: Mclaren Regional Medical Center Department of Family Medicine, Michigan State University College of Human Medicine, 401 South Ballenger Highway, Flint, MI 48532 USA.
authors.forename: Raghnild
authors.initials: R
authors.lastname: Bundesmann
authors.affiliation: Mclaren Regional Medical Center Department of Family Medicine, Michigan State University College of Human Medicine, 401 South Ballenger Highway, Flint, MI 48532 USA.
authors.forename: Samra
authors.initials: S
authors.lastname: Rashid