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.

Background: 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. Objective: 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. Methods: 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-related 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 P<.05. Results: 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 2.23-4.66; P<.001) for neurological injuries and was linked to a 4-fold increase in odds of 90-day mortality (OR 4.20, 95% CI 2.25-6.94; P<.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 1.09-2.41; P=.02), increasing age (aOR 1.01, 95% CI 1.00-1.03; P=.01), sustaining 1 or more injuries requiring admission (aOR 1.92, 95% CI 1.18-3.14; P=.01 vs aOR 3.69, 95% CI 1.95-6.98; P<.001), and a severe Kampala Trauma Score of ≤6 (aOR 2.71, 95% CI 1.37-5.37; P=.004). Conclusions: 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' perspectives to improve trauma care delivery in low-resource settings facing both prehospital and in-hospital barriers.