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External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study
  1. Idara J Edem1,
  2. Anna J Dare2,
  3. Peter Byass3,4,
  4. Lucia D’Ambruoso4,5,
  5. Kathleen Kahn4,
  6. Andy J M Leather6,
  7. Stephen Tollman4,
  8. John Whitaker6,
  9. Justine Davies7
  1. 1 Department of Surgery, Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada
  2. 2 Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  3. 3 Umeå Centre for Global Health Research, Umea Universitet, Umeå, Sweden
  4. 4 Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  5. 5 Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen School of Medicine and Dentistry, Aberdeen, UK
  6. 6 King’s Centre for Global Health, King’s Health Partners and King’s College London, London, UK
  7. 7 Centre for Applied Health Research, University of Birmingham, Birmingham, UK
  1. Correspondence to Dr Idara J Edem; iedem039{at}


Objective Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

Setting Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

Participants Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

Methods A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the ‘three delays framework’ (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs—a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

Results Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

Conclusions A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

  • trauma
  • avoidable death
  • verbal autopsy
  • rural
  • South Africa

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors IJE helped to develop the idea, did the analysis, drafted and revised the paper. AJD helped to develop the idea and inputted into the paper drafts. PB inputted into the idea and the paper drafts. LD inputted into the idea, supported the analyses and inputted into the paper drafts. AJML, KK and ST inputted into the idea and the paper drafts. KK set up and is overall responsible for the system of verbal autopsies. ST set up and is overall responsible for the Agincourt HDSS. JW contributed to the analyses and inputted into the paper drafts. JD led the project, developed the idea, supported the analyses and inputted into the paper drafts. All authors approved the final paper for submission.

  • Funding The research presented in this paper was funded by the Health Systems Research Initiative from the Department for International Development (DFID)/ Medical Research Council (MRC)/Wellcome Trust/Economic and Social Research Council (ESRC) (MR/P014844/1). A travel scholarship to enable this project was provided by the King’s College London, Centre for Global Health. Funding MR/P014844/1 has previously been used to develop the Verbal Autopsy data used in this study. These funding sources were not involved in this study design; in the collection, analysis and interpretation of the data; in the writing of the manuscript; and in the decision to submit the paper for publication.

  • Competing interests None declared.

  • Ethics approval Ethics approval from the University of the Witwatersrand Human Research Ethics Committee to use data from the VAs in the Agincourt HDSS in secondary analyses had been previously obtained (M960720 and M110138). All analysed VA data were anonymised and no individual deceased person or respondent was identifiable from the data used and presented. Ethics approval for the independent KIIs was obtained from the University of the Witwatersrand Human Research Ethics Committee (M170269) and King’s College London Research Ethics Committee (LRU-16/17–4313). Participation in the qualitative study was voluntary and informed consent was obtained for the interview and its recording. All interviews were confidential and narratives were anonymised.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data used for the VA analysis are available from the INDEPTH Data Repository platform at The supplementary file contains further details on the qualitative interviews. Further data analysis is available by emailing

  • Presented at This work has been previously presented at the following conferences: AANS 2018, New Orleans, USA, and CNIS Bethune Round Table 2018, Toronto, Canada.

  • Patient consent for publication Not required.

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