Explosive ordnance (EO) and explosive weapons (EW) inflict significant suffering on civilian populations in contemporary conflicts such as those in Yemen, Gaza, Sudan, and Ukraine, in addition to the ongoing consequences of contamination in post-conflict settings.1-3 4 Civilian casualties of EO have a nearly 40% mortality rate.5, Reference Pizzino, Waller, Tippett and Durham6 This figure is 5-20 times higher than that reported among blast-injured cohorts treated at military facilities or high-resource civilian centers. Reference Nunziato, Riley and Johnson7-Reference Edwards, Lustik and Carlson9 This mortality disparity is in large part due to the lack of a formalized casualty care continuum in many low-resource conflict and post-conflict settings where EO incidents occur in contrast with the well-developed trauma systems of military or high-resource civilian contexts. A range of factors including Lack of systematic community first aid response programs, limited or uncoordinated prehospital systems, underdeveloped trauma resuscitation/triage processes at facilities receiving casualties and insufficient trained surgical and anesthesia workforce all contribute to this gap. As the impact of EO including improvised explosive devices and the use of explosive weapons in populated areas affects civilians in conflicts globally, there is an urgent need for coordinated efforts to strengthen emergency care for civilian EO/EW casualties in low-resource settings.
At the 26th International Meeting of Mine Action National Directors and United Nations Advisers in 2023, the Explosive Weapons Trauma Care Collective (EXTRACCT) was established for this purpose.Reference Wild, Kushner, Loupforest and Stewart10 Humanitarian mine action (HMA) falls under the Global Protection Cluster within the humanitarian cluster system and is tasked with mitigating harm from EO through a range of activities including land clearance, explosive ordnance risk education (EORE), and victim assistance. Significant medical capacity is present on demining teams through medics trained in accordance with the International Mine Action Standards (IMAS) 10.40 on Medical Support to Demining Operations and in 2021, IMAS 13.10 on Victim Assistance in Mine Action was developed.11 Yet at present, few structured pathways exist for engagement between HMA and health stakeholders in EO/EW-affected settings to strengthen emergency care systems and improve trauma care for the injured.Reference Wild, Loupforest and Persi12
A systematic review was previously conducted to identify evidence-based opportunities for enhanced coordination between HMA and health stakeholders for implementation of trauma care interventions in low-resource settings affected by EO and EW.Reference Wild13 The findings of this review were synthesized into the Civilian Casualty Care Chain (C-CCC), a framework that built upon the continuum of care for the injured delineated by the World Health Organization (WHO)’s Emergency Care System Framework and highlights opportunities for HMA stakeholder involvement in trauma care capacity building for civilian EO/EW victims. To further elucidate the findings of this review, a qualitative analysis of key informant interviews was conducted with HMA sector stakeholders. The objective of these interviews was to qualitatively evaluate the experiences, perceptions, and recommendations of sector experts to increase HMA engagement with the emergency health response to civilian casualties of EO/EW. The findings of this study may help inform the design of interventions implemented jointly by HMA and health stakeholders to strengthen emergency care and reduce preventable death and disability among EO/EW casualties in low-resource settings.
Methods
Study Design
A cross-sectional qualitative study was conducted using a semi-structured guide to interview HMA sector experts (Supplement 1). Because victim assistance in mine action has historically focused heavily on long-term physical and psychosocial rehabilitation, this study focused on emergency care in the immediate post-injury setting. “Explosive ordnance” was defined in accordance with the IMAS 04.10 Glossary on mine action terms and “explosive weapons” was used to encompass all other forms of air- and ground-launched explosive munitions.3, 14 An initial convenience sample of participants was identified through discussions with key HMA stakeholders including the United Nations Mine Action Service and Antipersonnel Mine Ban Convention Implementation Support Unit. Subsequent participant recruitment relied on snowball sampling. Study participants were contacted via email for recruitment and verbal informed consent was obtained. Interviews occurred between November 2021-February 2022. Interviews were conducted until data saturation was achieved (i.e., lack of new themes or information yielded).Reference Saunders, Sim and Kingstone15
Data Management and Ethical Protections
Participants were interviewed anonymously. Organizational affiliation and professional role were documented and maintained in a separate de-identified spreadsheet accessed only by the study lead. Audio-recorded interviews were conducted by the lead author (HW). Interviews were held individually on a secure VPN and transcribed with personal identifiers redacted. Ethical approval for this study was granted by the University of Washington Human Subjects Division.
Data Analysis
Transcripts were manually evaluated for completeness and quality, and then analyzed using Dedoose 9.0.62 using deductive and inductive coding methods. Initial codes were derived directly from the interview tool (Figure 1), whereas inductive codes emerged in vivo.Reference Miles, Huberman and Saldana16 Each transcript was read and coded by 2 independent researchers (MT, CF). Analysis and coding occurred simultaneously until saturation was reached via an iterative process. Once generated, themes were then arranged by phase of care from point of injury to definitive care at health facility to maintain consistency with the C-CCC (Figure 2): layperson first response (i.e., bystander care prior to contact with first trained health care personnel), prehospital care (i.e., care rendered in the prehospital setting by trained health care personnel), facility-based casualty care (i.e., trauma care in the emergency unit; damage control resuscitation and surgery provided in health facilities), and system-wide measures of data collection and quality improvement.Reference Wild13
Civilian Casualty Care Chain (C-CCC)1
1. The C-CCC outlines a selected set of interventions that represent opportunities for HMA stakeholders to engage in health sector initiatives to improve emergency care of EW casualties. The C-CCC is not itself an emergency care pathway, as it lacks many of the emergency care system components needed for a continuum of response. Rather, it highlights specific areas of targeted action in which HMA stakeholders might leverage their existing capabilities, infrastructure, and operations to support local emergency care systems to improve trauma care for EW casualties.
2. Interdisciplinary refers to the interprofessional nature of robust emergency, critical, and operative care, engaging all relevant health care providers including physicians, surgeons, nurses, and health officers.
Coding tree.
Results
Participant Characteristics
Nineteen key informant interviews were conducted with sector experts in HMA, emergency care, humanitarian funding agencies, policy/advocacy, and academia (Table 1). Over half of the participants were affiliated with non-governmental organizations in the HMA sector (n=11; 58%). Numerous themes emerged encompassing a spectrum of care from point of injury to facility-based care (Table 2).
Interview participant characteristics
NGO – Nongovernmental organization
Selected quotes by theme
Layperson First Response
At the layperson first response phase, main themes included lack of a structured approach to improving bystander’s capacity to provide emergency first aid, prolonged time to reaching trained healthcare personnel, and underexplored opportunities to leverage existing local health care promotion efforts. Many EO/EW-affected regions are remote with limited organized prehospital care.Reference Husum, Gilbert, Wisborg, Van Heng and Murad17 Layperson first response refers to strengthening the capacity of community members and bystanders to equip them respond to life-threatening injuries (Figure 1). Participants in this study reported that currently, the needs of victims of EO- and EW-related injuries in conflict and post-conflict settings were frequently met first by local bystanders. Numerous participants recommended that training individuals in communities affected by explosive violence to perform safe extrication and basic life-saving interventions is an essential approach in regions where formal prehospital systems are resource-constrained.
“He spent 27 hours on route to get to a hospital after his injury, and that’s not an uncommon thing.”
“I think [the community] is where the first response really has to take place -- before you reach the facility and not to focus on the facility.”
Participants identified challenges to sustainability and scaling of layperson first responder (LFR) and other community-based trainings. Such challenges included a lack of clear pathways for longitudinal training as opposed to one-off interventions, access to basic equipment (e.g., personal protective equipment, hemorrhage control supplies), and contextual variation based on the local setting, conflict type, and EO/EW used. A clear opportunity for building on existing community-level interventions was identified leveraging EO risk education (EORE), a pillar of mine action through which existing community liaisons and community-based networks are established.18 Participants felt that existing teams of community liaisons would be well poised to deliver and sustain LFR trainings when integrated with EORE programs.
Numerous participants also highlighted the need to provide appropriate scene safety education and precautions to ensure that lay first responders did not expose themselves to risk of harm from EO/EW, unsafe infrastructure, and blood-borne pathogens. To address concerns about sustainability and integration with existing systems, several participants offered solutions including leveraging existing local personnel with relevant experience (e.g., individuals who worked as firefighters, nurses, or health care personnel prior to active conflict) or semi-formal connection with organized health systems (e.g., community health workers, civil servants) to whom educational and material support could be delivered through a train-the-trainer (ToT) approach. In addition, inconsistent bystander protection laws were viewed as a barrier to enhancing LFR capacity.
To reduce the time from point of injury to reaching a trained provider, participants raised the potential to leverage these community networks to create organized LFR transport systems using means of transportation available in the local context.Reference Mock, Tiska, Adu-Ampofo and Boakye19 At a policy level, such steps were felt to be consistent with IMAS 13.10Footnote a provisions regarding collaboration with health authorities to ensure access to emergency medical transport.
Prehospital Care
At the prehospital care phase, main themes included prolonged prehospital time prior to reaching facility-based care, lack of streamlined processes for understanding existing health system capacity, and lack of governance or coordination regarding HMA engagement with prehospital systems. In contexts where EO/EW-related injuries occur, participants frequently commented on the reality that prehospital transport can take many hours. To respond to this reality, participants felt that higher levels of training for those providing care in the prehospital setting are warranted.
Participants emphasized that establishing a clear understanding of existing medical facilities, capabilities, and capacity, including physical and human resources as well as fastest transport routes, are key for successful prehospital care (e.g., regular community-level updates/flyers about open facilities and safe passable roadways). In certain remote settings, health facilities were reported to not always be fully staffed; therefore it was recommended that such information be used to develop notification systems whereby facilities were alerted of incoming casualties to increase preparedness.
Individuals on HMA demining teams are all trained to the level of Basic Care Provider, with at least 1 Intermediate Care provider (paramedic-level trained individual) present at all times.11 Yet participants highlighted that, at present, there is little-to-no overlap between HMA medics and the care of civilian casualties. While demining teams feel a sense of responsibility to engage in prehospital care and transport of local accidents, injuries, or illnesses when they are coincidentally the first-on-site, there are no structured pathways for coordination between demining team medics and local emergency care providers, with the exception of nongovernmental organizations that engage in both land clearance and health provision activities (e.g., Humanity and Inclusion). Direct patient care was viewed as challenging both from a mandate and liability standpoint, which raised concerns over its acceptability and uptake:
“But that is obviously difficult…although they can work within the auspices of the [organization], if something goes wrong, that they were Samaritaning [sic] outside of that, there may be some very difficult laws about why you’re doing that when only doctors can put a line in and give tranexamic acid, we don’t even give tranexamic acid in our hospital. So what are you doing outside? So there’s, you know, there are some issues around legislation around that which make it difficult, I think what would be what would be useful to do instead is training.”
Numerous participants proposed that the integration of HMA personnel and medics into prehospital training could transform ad hoc engagement into systematic involvement in emergency care and trauma system capacity-building. For example:
“It does feel like a bit of a waste that quite well-trained medical people sat there for 8 hours a day. Clearly there’s a requirement. You can’t distract them with intensive training, but basic sort of ABCs of first aid and things like this…They could quite easily cover that without losing focus on that day-to-day task.”
Participants stated that it would be feasible to utilize medics during down-time at a safe periphery from the worksite or after-hours to conduct trainings for both lay persons and local prehospital care providers.
Facility-Based Care
At the facility-based care phase, main themes included inadequate clinical training in the management of severely injured patients, incomplete understanding of existing local health care capacity and referral pathways, lack of essential medication and equipment and facilities in regions affected by EO/EW with implications for casualty referral, and lack of formalized communication and handover procedures. Participants raised numerous issues surrounding care at the health facility level. In the experience of participants, many of the receiving facilities for injuries of EO/EW were felt to have insufficient training and material resources to provide high-quality damage control resuscitation and damage control surgery. Participants felt that these constraints could in part be mitigated by referral pathways, communication systems, and standardized health facility capacity mapping to create shared understanding of capabilities by site. For example, several participants described successful instances in which an initial receiving hospital lacked the imaging resources or surgical skillset for definitive care of specific injuries (e.g., fractures), yet was able to expedite care through immediate resuscitation with prompt referral to a tertiary hospital for subspecialty care. Opportunities for improvement included clarification of interfacility transfer and referral pathways or shared health actor mapping:
“We need to know if there’s a local clinic… If not, well, then we need to plan our evacuation routes another way. And then we start to understand the victims’ situation.”
Currently, such connections rely on relationships between providers more than formal communication pathways:
“In terms of integration with the Ministry of Health, no -- it would be normally individual hospitals, and the way it almost inevitably runs is someone will then have someone’s mobile phone number, and we’ll call them directly. We’ll usually get an anesthetist or a surgeon’s number or the lead for the hospital’s number, because there’s that sort of individual connection that’s been made. So that’s usually how it would run…it doesn’t normally go through bureaucracy of the Ministry of Health.”
While such connections were described to have facilitated access to care in individual cases, it was not felt to be a sustainable system and, further, it lacked integration with local Ministries of Health and health systems. This coordination gap was felt to create confusion around the appropriate routing of patients, ultimately creating delays in care.
In addition to improved notification systems and capacity mapping, opportunities for facility-based training were proposed. Several participants from the HMA sector proposed that creating partnerships for bidirectional refresher trainings for the care of blast-injured patients at health facilities could be mutually beneficial to HMA medical personnel through exposure to a hospital environment to maintain their clinical skills, while also improving the trauma and burn care training of local providers:
“Better trauma care for our own mine action personnel could mean better trauma care to communities where they’re working.”
“This is pushing at an open door at the moment, because senior people in [organization] are really keen on moving this aspect of care forward… in terms of teaching and training.”
Data Collection and Quality Improvement
Data collection was overall felt to be strong with respect to EO casualties and victims’ needs through sector-wide activities including community-based nontechnical surveys, as well as the minimum data requirements established by IMAS 5.10 on Information Management.20 In contrast, participants reported that these data were infrequently used to facilitate meaningful change for survivors and were not commonly operationalized into responsive programmatic changes or targeted interventions. Participants raised ethical concerns about data collection in the absence of clear pathways to improvement in services for the populations and communities from which data are being collected. As 1 participant stated,
“This humanitarian sector has been plagued…not necessarily an actual lack of data, but rather the lack of use of the data because there is a lot of gathering of data but with no clear purpose. So then there will be fatigue, of course, by both the people filling it in and also the people being asked.”
Other participants within HMA reported limitations in data analysis capacity that preclude data being fed back into evidence-based programming.
Discussion
A qualitative analysis of key informant interviews with HMA sector stakeholders was conducted to explore opportunities and challenges related to enhanced coordination with health stakeholders to improve emergency care for civilian casualties of EO/EW. Participant responses converged on several dominant themes, each yielding concrete intervention opportunities (Table 3). Key themes and recommendations included: (i) integrated LFR and EORE trainings to enhance community-level capabilities to effectively respond to EO incidents; (ii) leveraging HMA medics to strengthen of prehospital provider skills; and (iii) centralized processes for health facility mapping linked with structured prehospital casualty notification systems and referral pathways. While HMA stakeholders can potentiate the impact of emergency care-strengthening interventions, it is ultimately local, national, and multilateral health authorities who will drive these efforts and ensure their sustainability. It is therefore imperative that collaboration with Ministries of Health, local health care facilities, and emergency, critical, and operative care providers be strengthened. At present, most of the resource allocation in victim assistance is devoted to long-term rehabilitation. Sufficient support for strengthening emergency care elements of victim assistance is required to address these gaps in coordination.
Recommendations by phase of care
BTC – Blast Trauma Care; CFAR – community first-aid responder training; EMT – Emergency medical teams; EO – explosive ordnance; EORE – explosive ordnance risk education; EW – explosive weapons; HeRAMS – Health Resources and Services Availability Monitoring System; HMA – Humanitarian Mine Action; ICRC – International Committee of the Red Cross; IGOT – Institute for Global Orthopaedics and Traumatology; LFR – layperson first responder; SMART – Surgical Management and Reconstructive Training; WHO – World Health Organization.
Participants reiterated the importance of bystander care given the frequency with which community members are the first to respond to EO/EW accidents in regions that are remote or with weakened health infrastructure. LFR trainings have been successfully conducted in the past among communities affected by landmines. Specifically, numerous participants cited the efforts of the Tromsø Mine Victim Center as a successful intervention during which laypersons and prehospital personnel received intensive trauma care trainings in landmine-contaminated regions of Iraq and Cambodia in the 1990s. A 5-year prospective cohort study observed a reduction in trauma-related mortality in the intervention area from approximately 40%-15%. Yet, this intervention was not scaled throughout EO/EW-affected regions globally given a lack of sector-wide integration and buy-in.Reference Husum, Gilbert, Wisborg, Van Heng and Murad17 An additional factor of complexity was present in the Tromsø trainings, which included a paramedic-level component for prehospital personnel including advanced skills such as endotracheal intubation. Nonetheless, by more closely integrating LFR trainings into the activities of HMA stakeholders as well as local health care providers using a ToT model, this intervention has the potential to improve implementation outcomes (e.g., uptake, penetration, sustainability).Reference Proctor, Silmere and Raghavan21 Conversely, EORE trainings could be provided to community health care workers and other health care personnel to strengthen injury prevention in EO/EW-affected settings.
Participants recommended integration with EORE activities as a key opportunity for HMA engagement in dissemination of LFR trainings. EORE is a pillar of mine action with an extensive community-facing presence through nontechnical surveys and community liaisons. To ensure a continuum of care for the injured, it is essential to ensure that trained LFRs have a clear link with the health system with established mechanisms to alert and handoff to prehospital personnel or the nearest facility. With respect to health sector engagement, LFR trainings interface directly with the objectives stipulated by the recently endorsed WHO resolution on Integrated Emergency, Critical, and Operative Care (ECO resolution.76.2), including training of community first aid responders through the WHO community first aid responder (CFAR) program.22
Participants in this study reported that demining team medics and paramedics possessed currently underutilized potential to contribute to trauma care trainings for local prehospital personnel. Although the primary responsibility of HMA medical personnel universally is readiness for an incident during clearance activities, on-site incidents are thankfully relatively rare. Participants envisioned numerous arrangements via which medics could be leveraged to engage in trainings for local prehospital providers without compromising their primary responsibility to ensure the safety of demining teams. Such opportunities included trainings conducted at a safe periphery from a worksite, trainings conducted after-hours, and hiring arrangements for additional medic/paramedic shifts that could be devoted to weekly trainings. HMA teams should leverage globally accepted curricula for trauma care such as the WHO/International Committee of the Red Cross Basic Emergency Care Course and specific modules on conflict-related injury.
Though such activities could theoretically require additional resource allocation, participants identified this as having mutual benefit to mine action operators through (a) the inherent desire of local HMA personnel to give back to their communities, (b) increased acceptance among communities, and (c) favorable perceptions/competitive advantage in securing contracts through increased engagement in humanitarian health response activities. Formal intersectoral dialogue is needed to clarify opportunities for coordination at the prehospital level through mechanisms including Ministries of Health, locoregional health systems, and professional societies, and the WHO Emergency Medical Teams Initiative, all of which will be subject to contextual variability.23
Current practices for in-country health facility capacity assessment and mapping were felt to lack standardization and coordination. Participants described ad hoc relationships established with local surgeons/anesthetists for referral coordination at the health facility level. Participants also highlighted the redundancy of current practices in which each mine action operator performs their own organizational site visits and capacity evaluations. There was limited-to-no coordinated dialogue or engagement with ministries of health on this topic. Opportunities exist to streamline this process. A standardized process for facility mapping could be established with a mechanism for information-sharing between HMA stakeholders, thereby reducing redundancy and resource utilization expended during capacity assessments. These data should be shared and ultimately collected in collaboration with national Ministries of Health. Coordination could be facilitated by the Mine Action Area of Responsibility at the country level in collaboration with national mine action authorities if adequate capacity were devoted to victim assistance issues. Closer health stakeholder engagement would be mutually beneficial through leveraging of existing information in the WHO Health Resources and Services Monitoring Availability System, other WHO standardized assessment tools, and health cluster data, as well as improved integration with local health authorities such as ministries of health. IMAS 13.10Footnote b mandates mine action operators to collect data on relevant existing services in operations to help develop a directory of services compiled by the relevant government entity. Once synthesized, this facility mapping could be fed back to communities and LFR trainees to ensure clear notification pathways for EO/EW casualties.
This study had several limitations. First, study participants were recruited utilizing convenience and snowball sampling strategies, which may limit representativeness of the perspectives incorporated. This recruitment strategy, sample size, and sector-specific nature of the study’s objectives may limit generalizability and lead to premature saturation of themes. However, the sample represents a broad set of stakeholders with extensive experience in policy, health, and HMA including victim assistance. Second, voluntary response bias may be present, and those with less positive views of engagement between HMA and civilian casualty care may be less likely to be represented. This risk is felt to be low given that participants expressed both positive as well as potentially negative aspects or challenges encountered in coordination between HMA and emergency care for EO/EW victims. Third, study findings will require adaptation to specific local contexts and conflict dynamics. Our research group is engaged in ongoing work to address this gap, specifically a pilot of joint LFR trainings with EORE among IED-affected communities in Burkina Faso.Reference Wild, Loupforest and Persi12 Finally, while long-term physical and psychosocial rehabilitation for EO/EW victims is essential, the focus of this article is on strengthening emergency care to ensure that patients survive to reach the rehabilitative phase of care. Therefore, considerations surrounded strengthened long-term rehabilitation were not included in this study. Despite these limitations, our study provides current attitudes and perceptions around opportunities to enhance coordination between HMA and the emergency health response to EO/EW casualties that may be used to improve outcomes for civilians with explosive injuries in conflict and post-conflict settings.
Conclusion
Numerous opportunities exist to leverage medical capability present within humanitarian mine action to support emergency care strengthening in settings affected by EO/EW to reduce preventable death and disability among casualties. Key priorities include integration of layperson first responder trainings with explosive ordnance risk education activities and strategic utilization of mine action medics to support trauma care training for prehospital personnel. In addition, the benefits of service mapping by the mine action sector and the communication of locations where emergency medical should be reinforced, as per IMAS 13.10, can be leveraged to achieve improved coordination between HMA and health actors for mapping of in-country health facility capabilities with associated prehospital notification pathways and structured casualty referral. Increased support for the emergency care elements of victim assistance is required to facilitate these objectives. Clear mechanisms for integration of both layperson first responders and HMA personnel into local health care governance frameworks is required. To effectively achieve these goals, close collaboration and long-term coordination strategies with Ministries of Health and local health care personnel must be established.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2025.30.
Acknowledgments
Ethical approval for this study was granted by the University of Washington Human Subjects Division. All authors and study participants provided consent for publication of the manuscript in its final form with de-identified responses. Audio recordings are not available to protect study participants, but interview transcripts can be made available upon request to corresponding author for legitimate-use inquiries. The authors have no conflicts of interest or financial disclosures to declare.
Author contribution
HW – conceptualization, study design, data collection, data analysis, data synthesis, data visualization, writing of first draft of manuscript, manuscript revisions. MT, CF -- data analysis, data synthesis, data visualization, contributions to methodology section of first draft, manuscript revisions. CL, EH, SK, AM, ECH, ALK, BTS – manuscript revisions, expert advisory input, supervision.
Funding statement
HW is supported by the Global Health Equity Scholars Program NIH FIC and NIH OBSSR (Award no. D43TW010540)
Open access
