{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:43:58Z","timestamp":1785545038123,"version":"3.56.0"},"reference-count":52,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Hum Factors"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Trauma-related mortality exhibits a marked social gradient, driven by access barriers and health inequities worldwide. These barriers jeopardize progress toward Sustainable Development Goals 3 and 4.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aimed to investigate the prehospital and in-hospital barriers to timely injury care as perceived by frontline trainee physicians and traffic law enforcement professionals during real-time treatment execution in Uganda. Additionally, we aimed to highlight the potential impact of these barriers on trauma outcomes.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n This study used a convergent mixed methods approach. Qualitative data were collected through structured interviews and face-to-face focus groups with diverse teams of 500 frontline trainee physicians, including surgical residents, interns, medical students, and traffic law enforcement professionals. Directed content analyses for structured interviews and focus groups were conducted in NVivo (version 14, release 2023; QSR International). Quantitative data were concurrently collected using a survey questionnaire from the Motorcycle Trauma Outcome Registry, which included 1003 patients with trauma. We categorized barriers as prehospital or in-hospital barriers and as trauma team-related, patient-related, or health system\u2013related barriers. Multilevel restricted maximum likelihood logistic regression analyses of factors associated with barriers to injury care were analyzed using Stata (version 15.0; StataCorp LLC). Odds ratios (ORs) and 95% CIs were reported; statistical significance was defined as\n P<\/jats:italic>\n <.05.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Qualitative analyses identified key prehospital barriers, including delays in emergency medical services activation, ambulance arrival, and transportation. In-hospital barriers were primarily shortage of supplies, delays in identifying life-threatening injuries, and insufficient critical care services. Quantitatively, among the 1003 audited patients with trauma, 42% (416\/1003) faced barriers during treatment. The most common obstacles were delays in treatment decisions (232\/1003, 23%) and securing necessary supplies (180\/1003, 18%). The presence of barriers was independently associated with a 3-fold increased likelihood of unfavorable Glasgow Outcome Scale scores (OR 3.15, 95% CI 2.23\u20104.66;\n P<\/jats:italic>\n <.001) for neurological injuries and was linked to a 4-fold increase in odds of 90-day mortality (OR 4.20, 95% CI 2.25\u20106.94;\n P<\/jats:italic>\n <.001). After adjusting for injury severity and clustering effects by hospital teams and resources, the presence of barriers was associated with arrival by public means (adjusted OR [aOR] 1.62, 95% CI 1.09\u20102.41;\n P<\/jats:italic>\n =.02), increasing age (aOR 1.01, 95% CI 1.00\u20101.03;\n P<\/jats:italic>\n =.01), sustaining 1 or more injuries requiring admission (aOR 1.92, 95% CI 1.18\u20103.14;\n P<\/jats:italic>\n =.01 vs aOR 3.69, 95% CI 1.95\u20106.98;\n P<\/jats:italic>\n <.001), and a severe Kampala Trauma Score of \u22646 (aOR 2.71, 95% CI 1.37\u20105.37;\n P<\/jats:italic>\n =.004).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Multiple barriers to trauma care are more frequent for severe injuries and are associated with poorer neurological outcomes and higher mortality. These findings indicate the need for targeted, multifaceted interventions that incorporate frontline health workers\u2019 perspectives to improve trauma care delivery in low-resource settings facing both prehospital and in-hospital barriers.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/84774","type":"journal-article","created":{"date-parts":[[2026,6,10]],"date-time":"2026-06-10T18:43:14Z","timestamp":1781116994000},"page":"e84774-e84774","source":"Crossref","is-referenced-by-count":0,"title":["Understanding Barriers to Effective Injury Care by Medical Trainees and Traffic Law Enforcement First Responders in Low-Income Contexts in Uganda (Motor Registry Project Part 2): Convergent Mixed Methods Analysis"],"prefix":"10.2196","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0647-9716","authenticated-orcid":false,"given":"Herman","family":"Lule","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6686-1669","authenticated-orcid":false,"given":"Benson","family":"Oguttu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8591-7544","authenticated-orcid":false,"given":"Micheal","family":"Mugerwa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael Lowery","family":"Wilson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5925-5193","authenticated-orcid":false,"given":"Jussi P","family":"Posti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,6,10]]},"reference":[{"key":"R1","unstructured":"Laflamme L Burrows S Hasselberg M . Socioeconomic differences in injury risks: a review of findings and a discussion of potential countermeasures. World Health Organization. URL: https:\/\/apps.who.int\/iris\/handle\/10665\/350275 [Accessed 15-02-2026]"},{"key":"R2","doi-asserted-by":"publisher","DOI":"10.1016\/j.wneu.2022.06.031","article-title":"Racial and socioeconomic disparities in neurotrauma: research priorities in the New York metropolitan area through a global neurosurgery paradigm","volume":"165","author":"Barth\u00e9lemy","journal-title":"World Neurosurg"},{"issue":"1","key":"R3","doi-asserted-by":"publisher","DOI":"10.1186\/s13690-022-00891-6","article-title":"The burden of injury in Central, Eastern, and Western European sub-region: a systematic analysis from the Global Burden of Disease 2019 Study","volume":"80","author":"Haagsma","journal-title":"Arch Public Health"},{"key":"R4","doi-asserted-by":"publisher","DOI":"10.1016\/j.ienj.2020.100880","article-title":"Emergency trauma care in rural and remote settings: challenges and patient outcomes","volume":"51","author":"Morgan","journal-title":"Int Emerg Nurs"},{"issue":"3","key":"R5","doi-asserted-by":"crossref","first-page":"e109","DOI":"10.36834\/cmej.36925","volume":"8","author":"Luft","journal-title":"Can Med Educ J"},{"issue":"3","key":"R6","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1007\/s40719-022-00229-1","article-title":"Disparities in access to trauma care in Sub-Saharan Africa: a narrative review","volume":"8","author":"Alayande","journal-title":"Curr Trauma Rep"},{"issue":"Supp 1","key":"R7","doi-asserted-by":"publisher","first-page":"i96","DOI":"10.1136\/injuryprev-2019-043494","article-title":"Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017","volume":"26","author":"James","journal-title":"Inj Prev"},{"issue":"2","key":"R8","doi-asserted-by":"publisher","first-page":"278","DOI":"10.1016\/j.injury.2019.12.035","article-title":"Assessing barriers to quality trauma care in low and middle-income countries: a Delphi study","volume":"51","author":"Whitaker","journal-title":"Injury"},{"issue":"5","key":"R9","doi-asserted-by":"publisher","first-page":"371","DOI":"10.2471\/BLT.18.213074","article-title":"Trauma care and development assistance: opportunities to reduce the burden of injury and strengthen health systems","volume":"97","author":"Stewart","journal-title":"Bull World Health Organ"},{"issue":"5","key":"R10","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1097\/TA.0b013e31828c331d","article-title":"Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis","volume":"74","author":"Haider","journal-title":"J Trauma Acute Care Surg"},{"issue":"1","key":"R11","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1017\/S1049023X1600114X","article-title":"EMS systems in lower-middle income countries: a literature review","volume":"32","author":"Plummer","journal-title":"Prehosp Disaster Med"},{"issue":"3","key":"R12","doi-asserted-by":"publisher","first-page":"273","DOI":"10.1017\/S1049023X17000061","article-title":"The state of emergency medical services (EMS) systems in Africa","volume":"32","author":"Mould-Millman","journal-title":"Prehosp Disaster Med"},{"issue":"1","key":"R13","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-05508-8","article-title":"The state of emergency medical services and acute health facility care in Uganda: findings from a National Cross-Sectional Survey","volume":"20","author":"Ningwa","journal-title":"BMC Health Serv Res"},{"issue":"9","key":"R14","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2023-075117","article-title":"Barriers to equitable access to quality trauma care in Rwanda: a qualitative study","volume":"13","author":"Nzasabimana","journal-title":"BMJ Open"},{"key":"R15","doi-asserted-by":"publisher","DOI":"10.2147\/IJGM.S223882","article-title":"Identifying key challenges facing healthcare systems in Africa and potential solutions","volume":"12","author":"Oleribe","journal-title":"Int J Gen Med"},{"key":"R16","doi-asserted-by":"publisher","DOI":"10.3389\/fmed.2025.1522411","article-title":"Medical professionalism education: a systematic review of interventions, outcomes, and sustainability","volume":"12","author":"Sadeq","journal-title":"Front Med"},{"key":"R17","doi-asserted-by":"crossref","unstructured":"Al-Worafi YM . Medical and health sciences education training in developing countries: overview. In: Al-Worafi YM , editor. Handbook of Medical and Health Sciences in Developing Countries. Springer International Publishing; 2023:1-16. [doi: 10.1007\/978-3-030-74786-2_148-1]","DOI":"10.1007\/978-3-030-74786-2_276-1"},{"key":"R18","doi-asserted-by":"publisher","DOI":"10.2196\/55297","article-title":"Effect of rural trauma team development on the outcomes of motorcycle accident-related injuries (motor registry project): protocol for a multicenter cluster randomized controlled trial","volume":"13","author":"Lule","journal-title":"JMIR Res Protoc"},{"key":"R19","doi-asserted-by":"publisher","DOI":"10.2196\/82591","article-title":"Impact of rural trauma team development education on prehospital time, referral-to-dispatch interval, and neurological and musculoskeletal injury outcomes: cluster randomized controlled trial","volume":"13","author":"Lule","journal-title":"JMIR Hum Factors"},{"issue":"5","key":"R20","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2020-004324","article-title":"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","volume":"6","author":"Whitaker","journal-title":"BMJ Glob Health"},{"issue":"2","key":"R21","doi-asserted-by":"publisher","first-page":"170","DOI":"10.1080\/17457300.2018.1535511","article-title":"Road traffic injuries in Uganda: pre-hospital care time intervals from crash scene to hospital and related factors by the Uganda Police","volume":"26","author":"Bayiga Zziwa","journal-title":"Int J Inj Contr Saf Promot"},{"issue":"1","key":"R22","doi-asserted-by":"publisher","DOI":"10.1186\/s12873-017-0137-2","article-title":"Weaknesses and capacities affecting the prehospital emergency care for victims of road traffic incidents in the greater Kampala metropolitan area: a cross-sectional study","volume":"17","author":"Balikuddembe","journal-title":"BMC Emerg Med"},{"issue":"1","key":"R23","doi-asserted-by":"publisher","first-page":"1175","DOI":"10.3126\/nje.v12i1.43633","article-title":"The growing importance of mixed-methods research in health","volume":"12","author":"Wasti","journal-title":"Nepal J Epidemiol"},{"issue":"1","key":"R24","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1093\/neuros\/nyy004","article-title":"Temporal delays along the neurosurgical care continuum for traumatic brain injury patients at a tertiary care hospital in Kampala, Uganda","volume":"84","author":"Vaca","journal-title":"Neurosurgery"},{"issue":"2","key":"R25","doi-asserted-by":"publisher","first-page":"92","DOI":"10.1258\/jhsrp.2007.007074","article-title":"The quality of mixed methods studies in health services research","volume":"13","author":"O\u2019Cathain","journal-title":"J Health Serv Res Policy"},{"issue":"6","key":"R26","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item checklist for interviews and focus groups","volume":"19","author":"Tong","journal-title":"Int J Qual Health Care"},{"issue":"1","key":"R27","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1097\/SP9.0000000000000013","article-title":"Rural trauma team development training amongst medical trainees and traffic law enforcement professionals in a low-income country: a protocol for a prospective multicenter interrupted time series","volume":"28","author":"Lule","journal-title":"Int J Surg Protoc"},{"issue":"1","key":"R28","doi-asserted-by":"publisher","DOI":"10.1186\/s12909-025-06755-1","article-title":"Prospective multi-centre analysis of rural trauma team development training for medical trainees and traffic law enforcement professionals in Uganda: an interrupted time series study","volume":"25","author":"Lule","journal-title":"BMC Med Educ"},{"key":"R29","unstructured":"Lule H Mugerwa M Abio A et al. Motorcycle Trauma Outcome Registry (MOTOR) trial dataset. Mendeley Data; 2025. [doi: 10.17632\/BGPMKPCWDT.1]"},{"key":"R30","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2021.114523","article-title":"Sample sizes for saturation in qualitative research: a systematic review of empirical tests","volume":"292","author":"Hennink","journal-title":"Soc Sci Med"},{"key":"R31","doi-asserted-by":"publisher","DOI":"10.1016\/j.glmedi.2024.100171","article-title":"Sample size for saturation in qualitative research: debates, definitions, and strategies","volume":"5","author":"Ahmed","journal-title":"J Med Surg Public Health"},{"key":"R32","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnsa.2024.100174","article-title":"Saturation in qualitative research: an evolutionary concept analysis","volume":"6","author":"Rahimi","journal-title":"Int J Nurs Stud Adv"},{"key":"R33","doi-asserted-by":"publisher","DOI":"10.1136\/ip-2025-045737","article-title":"Factors associated with all-cause mortality and morbidity of motorcycle crash-related neurological and musculoskeletal injuries in Uganda: the MOTOR cluster randomised trial ancillary study","author":"Lule","journal-title":"Inj Prev"},{"issue":"1","key":"R34","doi-asserted-by":"publisher","DOI":"10.1186\/s12873-024-01048-0","article-title":"New trauma score versus Kampala Trauma Score II in predicting mortality following road traffic crash: a prospective multi-center cohort study","volume":"24","author":"Damulira","journal-title":"BMC Emerg Med"},{"issue":"2","key":"R35","doi-asserted-by":"publisher","first-page":"101124","DOI":"10.1016\/j.aucc.2024.09.009","article-title":"Methods of functional outcome assessment in neurocritical care trials: a systematic review and meta-analysis","volume":"38","author":"Fitzgerald","journal-title":"Aust Crit Care"},{"issue":"1","key":"R36","doi-asserted-by":"publisher","first-page":"2309499019890140","DOI":"10.1177\/2309499019890140","article-title":"Evaluation of an expectation and outcome measurement questionnaire in ankle fracture patients: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) Eurasia study","volume":"28","author":"Fang","journal-title":"J Orthop Surg (Hong Kong)"},{"key":"R37","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2019.103208","article-title":"The REDCap consortium: building an international community of software platform partners","volume":"95","author":"Harris","journal-title":"J Biomed Inform"},{"issue":"4","key":"R38","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2021-008256","article-title":"Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa","volume":"7","author":"Equi-Trauma Collaborative","journal-title":"BMJ Glob Health"},{"issue":"1","key":"R39","doi-asserted-by":"publisher","DOI":"10.1186\/s12873-026-01480-4","article-title":"Trauma handover practices between ambulance clinicians, emergency department staff and trauma teams: scoping review","volume":"26","author":"Harthi","journal-title":"BMC Emerg Med"},{"issue":"3","key":"R40","doi-asserted-by":"publisher","DOI":"10.1002\/emp2.12974","article-title":"How do current police practices impact trauma care in the prehospital setting? a scoping review","volume":"4","author":"Salhi","journal-title":"J Am Coll Emerg Physicians Open"},{"key":"R41","doi-asserted-by":"publisher","DOI":"10.1080\/00185868.2025.2542447","article-title":"Navigating health systems: a scoping review of WHO Building Blocks and Control Knobs frameworks","author":"Jauhar","journal-title":"Hosp Top"},{"issue":"9","key":"R42","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0308525","article-title":"Identifying and prioritising barriers to injury care in northern Malawi, results of a multifacility multidisciplinary health facility staff survey","volume":"19","author":"Whitaker","journal-title":"PLoS One"},{"issue":"11","key":"R43","doi-asserted-by":"publisher","first-page":"e1196","DOI":"10.1016\/S2214-109X(18)30386-3","article-title":"High-quality health systems in the Sustainable Development Goals era: time for a revolution","volume":"6","author":"Kruk","journal-title":"Lancet Glob Health"},{"issue":"4","key":"R44","doi-asserted-by":"publisher","DOI":"10.3390\/healthcare13040352","article-title":"Assessing the relationships of expenditure and health outcomes in healthcare systems: a system design approach","volume":"13","author":"V\u0103rzaru","journal-title":"Healthcare (Basel)"},{"issue":"6","key":"R45","doi-asserted-by":"publisher","first-page":"1163","DOI":"10.1007\/s00590-021-03080-3","article-title":"Barriers to trauma care in south and central America: a systematic review","volume":"32","author":"Kinder","journal-title":"Eur J Orthop Surg Traumatol"},{"issue":"1","key":"R46","doi-asserted-by":"publisher","DOI":"10.1111\/ajr.13216","article-title":"Trauma outcomes based on remoteness of injury in Australia: a systemic review","volume":"33","author":"Hafeez-Baig","journal-title":"Aust J Rural Health"},{"issue":"9554","key":"R47","doi-asserted-by":"publisher","first-page":"2243","DOI":"10.1016\/S0140-6736(06)68895-8","article-title":"Reducing inequalities from injuries in Europe","volume":"368","author":"Sethi","journal-title":"Lancet"},{"issue":"12","key":"R48","doi-asserted-by":"publisher","first-page":"e1978","DOI":"10.1016\/S2214-109X(23)00489-8","article-title":"Converging global health agendas and universal health coverage: financing whole-of-government action through UHC","volume":"11","author":"Collins","journal-title":"Lancet Glob Health"},{"issue":"7","key":"R49","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000041535","article-title":"Sustainable Development Goals (SDGs) and resilient healthcare systems: addressing medicine and public health challenges in conflict zones","volume":"104","author":"Ugwu","journal-title":"Medicine (Baltimore)"},{"key":"R50","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-11-44","article-title":"Parametric methods outperformed non-parametric methods in comparisons of discrete numerical variables","volume":"11","author":"Fagerland","journal-title":"BMC Med Res Methodol"},{"issue":"3","key":"R51","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1111\/cgf.14521","article-title":"Effective use of Likert scales in visualization evaluations: a systematic review","volume":"41","author":"South","journal-title":"Comput Graph Forum"},{"issue":"1","key":"R52","doi-asserted-by":"publisher","DOI":"10.1177\/21582440221079922","article-title":"Paradigmatic compatibility matters: a critical review of qualitative-quantitative debate in mixed methods research","volume":"12","author":"Liu","journal-title":"Sage Open"}],"container-title":["JMIR Human Factors"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/humanfactors.jmir.org\/2026\/1\/e84774","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T22:25:57Z","timestamp":1785536757000},"score":1,"resource":{"primary":{"URL":"https:\/\/humanfactors.jmir.org\/2026\/1\/e84774"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,10]]},"references-count":52,"URL":"https:\/\/doi.org\/10.2196\/84774","relation":{},"ISSN":["2292-9495"],"issn-type":[{"value":"2292-9495","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,10]]},"article-number":"v13i1e84774"}}