{
  "abstract": "Background Around 40% of mortality after injuries is avoidable with access to quality care. Investments in interventions which maximise the number of injured persons who access and receive quality care are paramount, especially in low-resourced settings. Selecting such interventions within complex adaptive health systems is challenging due to the multiple interactions within these systems.Methods We created a conceptual map, or causal loop diagram (CLD), representing the health system for injury care, focused on challenges to improving patient outcomes in low- or middle-income countries (LMICs). We used the stages of seeking, reaching, receiving and remaining in care as the care pathway framework to conceptualise the diagram. Based on expert opinion and literature searches, we elicited micro (patient and their family), meso (health service) and macro (country context) factors which affect access to quality care at each stage of the care pathway and mapped interactions between them. Factors and their interactions were adjusted during a workshop with external experts. A CLD was created using Vensim to show relationships between all factors at all stages of the care pathway. Feedback loops within the CLD which are either reinforcing (perpetuating positive or negative change) or balancing (limiting change) were elicited. Leverage points were identified as factors which are present in multiple causal loops and are potential intervention points for maximal change.Results We initially identified 41 factors affecting stage 1, 13 affecting stage 2, 51 affecting stage 3 and 49 affecting stage 4. Consolidating factors of a similar theme gave 45 unique factors for the overarching model; 13 micro, 20 meso and 12 macro. We constructed two CLDs—one for the overarching health system and the other focused on healthcare services at facilities. The health service-specific map contained 22 meso factors. We identified 928 reinforcing or balancing causal loops acting within the health system for injury care affecting health outcomes. Factors acting as leverage points involved in the largest number of feedback loops relate to trust in or perceptions of the health system (748 loops and 694 loops, respectively) and willingness to seek care (636 loops). The health service-focused CLD identified funding and the provision of quality care as the main leverage points (112 loops each).Discussion Our work, using injury care as an exemplar, moves beyond understanding the impact of factors on patient outcomes in silos. Rather, in considering comprehensive connections between all factors on outcomes, we show interactions which could lead to unintended consequences and rapidly worsen or improve health outcomes. Our identification of trust and willingness to seek care as key leverage points suggests these should be focal points for research and investment.",
  "authors": [
    {
      "affiliations": [
        "Department of Applied Health Research, University of Birmingham, Birmingham, UK",
        "Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa"
      ],
      "name": "Justine I Davies"
    },
    {
      "affiliations": [
        "Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa"
      ],
      "name": "Kathryn Chu"
    },
    {
      "affiliations": [
        "Centre for Global Surgery, Stellenbosch University, Stellenbosch, South Africa",
        "Centre for Global Development, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK"
      ],
      "name": "Lucia D’Ambruoso"
    },
    {
      "affiliations": [
        "Centre for Health Economics, York University, York, UK"
      ],
      "name": "Laura Bojke"
    },
    {
      "affiliations": [
        "Department of Health Systems and Public Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa"
      ],
      "name": "Rene English"
    },
    {
      "affiliations": [
        "Emergency and Clinical Services Support, Western Cape Government Department of Health and Wellness, Cape Town, South Africa"
      ],
      "name": "Heike Geduld"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa"
      ],
      "name": "Sa’Ad Lahri"
    },
    {
      "affiliations": [
        "Metro Health Services, Western Cape Department of Health and Wellness, Western Cape Government, Cape Town, South Africa",
        "Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa"
      ],
      "name": "Hassan Mahomed"
    },
    {
      "affiliations": [
        "School of Public Health, Faculty of Health Sciences, University of Cape Town, Rondebosch, South Africa",
        "Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa"
      ],
      "name": "Richard Matzopoulos"
    },
    {
      "affiliations": [
        "Nottingham Business School, Nottingham Trent University, Nottingham, UK"
      ],
      "name": "Antuela A Tako"
    }
  ],
  "title": "A systems approach to understanding injury care in LMICs using causal loop diagrams",
  "uid": "4cfb0204-9a84-5539-ac9b-94b779d8369b"
}