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Original research
Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments
  1. John Whitaker1,2,
  2. Nollaig O'Donohoe3,
  3. Max Denning4,5,
  4. Dan Poenaru6,
  5. Elena Guadagno6,
  6. Andrew J M Leather1,
  7. Justine I Davies7,8,9
  1. 1King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
  2. 2Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
  3. 3Department of Colorectal Surgery, King's College London, London, UK
  4. 4Department of Surgery and Cancer, Imperial College London, London, UK
  5. 5Stanford Graduate School of Business, Stanford University, Stanford, California, USA
  6. 6Harvey E Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
  7. 7Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
  8. 8Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa
  9. 9Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  1. Correspondence to Professor Justine I Davies; j.davies.6{at}bham.ac.uk

Abstract

Background The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

Methods We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

Results Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

Conclusions Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

  • injury
  • traumatology
  • health systems evaluation
  • health services research
  • health systems

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2020-004324

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information.

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    Footnotes

    • AJML and JID are joint senior authors.

    • Handling editor Soumyadeep Bhaumik

    • Twitter @maxdenning1, @drjackoids

    • Contributors JW, JID and AJML conceived of the project. JW, JID, AJML, DP and EG developed the study design. EG conducted the database search. JW, MD and NO'D conducted screening and data extraction. JW conducted the analysis and synthesis and wrote the first draft. All authors contributed to manuscript revisions and approve the final version.

    • Funding MD is supported by a graduate fellowship award from Knight-Hennessy Scholars at Stanford University. JW is a serving member of the UK Defence Medical Services.

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    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.