To conduct a systematic review and narrative synthesis to identify barriers, facilitators and pre-existing interventions and describe the current status of initiatives/interventions aimed at improving access to quality trauma healthcare after injury in Pakistan.

Systematic review and narrative synthesis

MEDLINE (Ovid), Embase (Ovid), Web of Science (Clarivate Analytics), Cochrane (Wiley), Scopus and ProQuest, as well as grey literature.

Full-text peer-reviewed publications, including cross-sectional studies, cohort studies, case-control studies, randomised controlled trials and qualitative studies published in English from January 2013 to December 2023.

Two independent reviewers used a standardised tool to extract data variables to Excel. The quality of the included studies was evaluated using the CASP checklist. The barriers, facilitators and pre-existing interventions were mapped using the four delays framework, the Institute of Medicine (IOM) quality domains and the WHO health systems building blocks. The data were synthesised narratively to improve access to quality trauma care in Pakistan. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines.

The review included 20 studies. 19 studies reported 58 barriers to access to quality care. Six studies reported 20 facilitators, and eight studies described initiatives or interventions aimed at improving access to quality trauma healthcare after injury. According to the four delays framework, the receiving care stage of access to care was primarily studied in 16 studies, which identified 37 barriers and 13 facilitators across 5 studies. Regarding the quality of care according to IOM domains, the effectiveness of quality trauma care after an injury was studied in 15 studies, which identified 19 barriers and 10 facilitators across four studies. According to the WHO health system building blocks, most studies (n=15) described challenges in healthcare service delivery, with these 15 studies identifying 23 barriers and 3 studies identifying 4 facilitators.

Our findings highlighted the scarcity of available literature, identified barriers and facilitators and pre-existing interventions, which informed the need to develop feasible, sustainable and contextually relevant interventions to improve access to quality trauma care after injury in Pakistan.

CRD42024545786

Injury is a major cause of death in Rwanda, with many deaths occurring before hospital admission. Timely transport of injured patients to appropriate hospitals is crucial, ideally within an hour for severely injured patients. However, delays in reaching treatment facilities are common, with ambulance services using inefficient mobile phone communication. This project aims to evaluate the effectiveness and implementation of an innovative electronic communication platform (912Rwanda).

The study will be conducted through the public ambulance service, Service d’Aide Médicale d’Urgence (SAMU), and receiving health facilities in Kigali city and Musanze district in Rwanda. The 912Rwanda intervention will be rolled out in the two locations at different times. The primary effectiveness outcome is the time from ambulance deployment to patient arrival at the health facility. Secondary effectiveness outcomes include disaggregated times of the primary outcome and clinical outcomes, such as length of stay and requirement for intensive care. These outcomes will be evaluated using an interrupted time series analysis, accounting for non-homogeneous variances, auto-regressive errors and non-linear trends where appropriate. Implementation outcomes will be evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Qualitative Evaluation for Systematic Translation (QuEST) framework. Cost-effectiveness will be evaluated using a cost-consequence analysis with consequences as determined by the interrupted time series analysis.

Ethical approval was obtained from the Rwanda National Research Ethics Committee (Ref No: 99/RNEC/2023). Dissemination will occur through open-access peer-reviewed publications, relevant national and international conferences.

ISRCTN97674565.

To evaluate inhaler sustainability in asthma and Chronic Obstructive Pulmomary Disease (COPD) by analysing how inhaler design typology, prescribing and usage patterns, disposal and recycling practices influence human health and environmental outcomes, using a People-Process-Product (PPP) framework to identify actionable opportunities for improvement.

A systematic review was conducted in May 2024, with reporting structured around the PPP framework using narrative synthesis.

MEDLINE, Scopus, Cochrane Library and relevant grey literature were searched for publications over the period from April 2014 to April 2024.

Studies were included if published between 2014 and 2024, involved patients with asthma or COPD and healthcare professionals and specifically examined aspects of inhaler sustainability, including patient behaviours, healthcare provider prescribing practices and environmental impacts.

Two independent reviewers screened and extracted data from 63 studies. Due to diverse methodologies, quality assessment focused on research design robustness, completeness of outcome reporting and potential biases. Findings were synthesised narratively to address each research question using the PPP framework.

33% of included studies focused on two or more domains of the PPP framework as both primary and/or secondary outcomes. Studies mapped to the ‘People’ domain (n=34) showed limited awareness among patients and clinicians regarding the environmental impact of inhaler prescription patterns, use patterns and disposal methods, with over 75% of patients discarding inhalers in household waste. In the ‘Process’ domain (n=11), switching from pressurised metered-dose inhalers (pMDIs) to dry powder inhalers (DPIs) or soft mist inhalers (SMIs) was associated with improved inhaler adherence and asthma control, though uptake of new inhalers was influenced by patients’ prior experience, competence, proficiency and perceived usability. The ‘Product’ domain (n=41) showed that DPIs and SMIs consistently had lower carbon footprints than pMDIs, with short-acting beta-agonists (SABAs) pMDIs having the highest emissions due to prescription, use patterns and disposal.

Improving patient education on sustainable inhaler use and disposal and providing healthcare professionals with focused training on low-carbon prescribing are critical steps towards achieving significant clinical benefits and supporting environmental sustainability in asthma and COPD management.

CRD42024541927.