ABSTRACT

Background Injury-related mortality exhibits a significant social gradient, particularly in low-middle-income countries (LMICs), with approximately 4.5 million premature deaths annually.

Objective This study explores prehospital and in-hospital barriers to timely injury care as perceived by frontline healthcare personnel in Uganda.

Methods We utilized a mixed methods approach, gathering qualitative data from five hundred frontline workers including surgical residents, interns, and law enforcement professionals, alongside quantitative data from 1,003 trauma patients. Barriers were categorized into pre- and in-hospital trauma team-related, patient-related, and systemic healthcare challenges.

Results From frontline workers, prehospital barriers included delays in emergency medical services activation (21.2%), ambulance arrival (19.3%), and transportation to hospitals (15.2%) whereas in-hospital barriers primarily involved supply shortages (28.3%), delays in identifying life-threatening injuries (27.3%), and insufficient critical care services (26.3%). Among the 1003 audited trauma patients, 41.5% (n=416) faced barriers during treatment. The most common barriers were delays in treatment decisions (n=232, 23.1%) and securing necessary supplies (n=180, 17.9%). Presence of a barrier correlated with higher odds of unfavourable Glasgow Outcome Scale scores compared to those without barriers [OR 1.750, 95% CI (1.497-2.047) vs. OR 0.556, 95% CI (0.436-0.708), p<0.001]. Moreover, the odds of mortality were higher for those whom a barrier was encountered compared to those where there was no barrier [OR 1.901, 95% CI (1.057-3.420) vs. OR 0.588, 95% CI (0.397-0.869), p<0.001].

Conclusions Our findings highlight the need for multifaceted targeted interventions, integrating frontline healthcare perspectives to improve trauma care delivery in LMICs which face both prehospital and in-hospital disparities to accessing injury care.

Competing Interest Statement

The authors have declared no competing interest.

Clinical Trial

Pan African Clinical Trial Registry: PACTR202308851460352

Clinical Protocols

https://pmc.ncbi.nlm.nih.gov/articles/PMC11109866/

https://pmc.ncbi.nlm.nih.gov/articles/PMC10905493/

Funding Statement

The study received funding through fellowships for HL from the University of Turku Graduate School, the Turku University Hospital (TYKS) Foundation, the TYKS Neurocenter, and the Center for Health Equity in Surgery and Anaesthesia (CHESA) at the University of California San Francisco (UCSF). Additionally, JPP was supported by grants from the Academy of Finland (Grant No. 60063) and the Maire Taponen Foundation. The funding agencies had no role in the design, execution, or reporting of the research findings.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval for this research involving human participants was obtained from the Research and Ethics Committees of Mbarara University of Science and Technology (Reference: 1/7; 05/5-9) and the Uganda National Council for Science and Technology (Reference: SS 5082).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Data availability statement

The data collection tools and anonymized datasets pertaining to this study and the parent trial (Pan African Clinical Trial Registry: PACTR202308851460352), are publicly accessible [16], [20], [21].

List of abbreviationsGOSGlasgow Outcome ScaleHICSHigh-Income CountriesLMICsLow-Middle-Income CountriesTEFSTrauma Expectation Factor ScoreTOMSTrauma Outcome Measure Score