The rapid evaluation of trauma healthcare systems in low- and middle-income countries using the Three Delays framework

Student thesis: Doctoral ThesisDoctor of Philosophy


Trauma and injuries represent a vast and relatively neglected burden of disease, predominantly affecting low- and middle-income countries (LMIC) where outcomes are worse than high-income counterparts. A whole health system assessment approach offers a potential benefit in better researching, understanding and addressing this substantial, neglected and unequal burden of disease. Efficiently assessing injury health systems offers potential benefits for all stakeholders. In my thesis, I develop and use a Three Delays framed mixed-method assessment to evaluate the trauma health system serving Karonga HDSS, Northern Malawi. I also appraise the suitability of the methods for future use in rapid health system assessments elsewhere.
In the first chapter, I set the scene for why a rapid assessment of trauma health systems is important and how the Three Delays framework (considering delays to seeking, reaching and receiving care) can help. This PhD is supported by the British Army and Defence Medical Services. Therefore, in chapter two, I provide the context and background for why global health research in general, and LMIC trauma health system research in particular, are of relevance and importance for militaries.
The third chapter is a systematic literature review and evidence synthesis mapping the Three Delays framework to injury health system assessments within LMICs. I found few studies considered the whole health system as understood by the Three Delays framework, with assessments of facility capacity dominating the literature. Most studies used methods that could potentially be applied within a rapid assessment. However, innovating and combining methods to generate insight into Delays 1 and 2, and evaluating the quality of care processes and outcomes, require greater attention.
In chapter four, I present a Delphi study to establish expert consensus on the most important barriers, within a Three Delays framework, to accessing quality injury care in LMICs, that should be considered when evaluating a health system. I identified 20 distinct barriers potentially delaying care following injury in LMICs. Categorised within a Three Delays framework, expert participants reached consensus of agreement that eleven barriers were easy to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability for affected injured persons, and could potentially be readily changed to improve care for injured patients.
I, therefore, drew on the systematic literature review and Delphi study findings to inform the selection and development of methods used in my injury healthcare system assessment. In chapter five, I describe the methods used to assess the injury health system serving the Karonga Health and Demographic and Surveillance Site (HDSS), Malawi. The study components are 1) household survey; 2) verbal autopsy database analysis; 3) community focus group discussions); 4) community photovoice study; 5) facility process mapping study of the care pathway and barriers following injury; 6) a survey of facility healthcare workers; 7) facility assessment survey; 8) clinical vignettes for care process quality assessment of healthcare workers; and 9) geographic information system analysis. I also describe the mixed-method integrated analytical approach used.
In chapter six I report the non-integrated results from each of my study findings within a vertical study component analysis. In chapter seven, I present the integrated mixed-method analysis of the health system assessment. The novel approach to integrating nine different studies, including qualitative, quantitative, community, patient and healthcare worker derived data sources, offered a rich insight into this health system's functioning, using a Three Delays theoretical lens. This integrated analysis highlights the existence of important barriers to seeking, reaching and receiving care within the Karonga HDSS health system. The perceived financial cost associated with seeking care, despite a primarily government-funded health system with no user fees, was found to have strong convergent evidence as important barriers to seeking care. So too was a lack of community health and healthcare literacy. In the absence of a formal prehospital emergency care system, quickly finding affordable, suitable transport to cover the long distances, particularly to referral facilities, involving unreliable roads susceptible to weather, were found to have strong convergent evidence as important barriers to reaching care. The expected limited availability of physical resources within facilities, and challenges with the availability of motivated, trained staff, including specialists, were strongly evidenced as important barriers to receiving quality facility-based care. These insights provided a rich understanding of and evidence for various health system barriers to consider when planning improvements to the health system response to the injured patient in this and similar contexts. In the final chapter, I appraise the generalisable methodological learning from the thesis. I critically reflect upon the utility of studied methodological approaches in a rapid health system assessment and potential ways to improve their application.
My thesis sheds light on the relatively under-researched and less-resourced injury care health system in Northern Malawi. Focussing on the broader injury care health system inclusive of health-seeking and care access, helps fill a gap within Malawian trauma care research, which, as in many LMICs, is facility-centric. Further, my thesis makes an important contribution to the existing literature in applying mixed-methods approaches to such health system research. Integrating nine different methods through a joint matrix display to inform a deep system understanding of a single population is novel in both depth and focus and should encourage debate and use of such approaches for similar future studies. This is particularly the case in LMIC trauma care research, where mixed-methods studies are rare. This study also advances the health systems research application of the Three Delays framework into the fields of emergency care and trauma. Future post-doctoral use of this approach in trauma health system research is planned with funding applications in progress. Undertaking this PhD thesis has facilitated my academic growth and experience with multiple research approaches and methods. It has developed my cultural competence and boundary spanning skills and experience valuable to future academic pursuit in the arenas of both Health Systems Research and Military Global Health Engagement.
Date of Award1 Aug 2021
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorAndrew Leather (Supervisor) & Justine Davies (Supervisor)

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