Assessing barriers to quality trauma care in low and middle-income countries: A Delphi study

•This study developed expert consensus on the most important barriers to consider when evaluating an LMIC health system's preparedness to deliver injury care.•Twenty conceptual barriers were identified and categorised within a three delays framework.•11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable.•The findings can guide evaluation of injury care health systems in LMIC settings and inform prioritisation of interventions to improve care. Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system. A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement. There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus. 11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.