Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review

Background: An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs. Methods: This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle–Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies. Conclusions: The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.


Introduction
Most of the deaths from trauma, heart attacks, stroke, or any other time-sensitive illnesses occur within the first hour (golden hour) and usually out of the hospital. 1 Prehospital care is thus a crucial part of emergency medical care and can greatly affect health outcomes. 2 The importance of prehospital emergencies is often neglected in low-and middleincome countries (LMICs), 3 and this translates into a substantial toll of avoidable deaths from time-sensitive conditions such as injuries, cardiac problems, and obstetric emergencies. 4 Not only to traumatic patients, prehospital care is equally essential to obstetric as well as communicable and non-communicable disease patients. 5 A major proportion of deaths from injuries, especially due to road traffic accidents (RTAs), occurs in LMICs with a large proportion of those deaths occurring before reaching the hospital. 6 Poor road safety and the lack of appropriate and timely care for injured individuals might be the causes of this high number of deaths. 7 Care of the injured person due to an accident starts before arrival in the hospital, and it is believed that prompt and efficient prehospital care reduces morbidity and mortality associated with RTAs. 8 This critical care helps to stabilize patients and prepare them for transport to a health care facility by providing timely and appropriate care in the prehospital setting. 9 Studies have reported that a significant proportion of deaths and disabilities can be reduced by well-organized prehospital care or Emergency Medical Services (EMS). 10,11 The key components of EMS, namely notification (time from scene to receipt of call by the dispatch team), activation (time from receipt of call to dispatch), response (time from dispatch to arrival at the scene), on-scene (time from arrival at the scene to departure), and transport (departure from the scene to arrival at the hospital) play a vital role in timely, effective, and integrated care. [12][13][14] In LMICs, it is common to witness limited access to health care facilities or trained medical personnel, so prehospital care provided by first responders or other trained emergency medical technicians (EMTs) can make a crucial difference in the outcome of a medical emergency. 15 The rapid arrival of an ambulance at the scene/patients coupled with trained emergency medical personnel and adequate victim transportation to the hospital may mitigate morbidity, prevent disability, and enhance the survival of patients with time-sensitive illnesses. 16 As the first point of contact between patients and the emergency care department, dispatching unit personnel not only assess the urgency of a call and dispatch a team accordingly, they also try to give counseling to the caller to minimize the consequences of the emergency and manage the patient/victim. 17 Quality prehospital emergency care can make an important contribution to reducing avoidable deaths and disabilities, but the public health system has never prioritized emergency medical care, especially in developing countries. [18][19][20] The availability of quality prehospital care causes a significant reduction in traumarelated mortality alone. 21 It is also the foundation for effective disaster response and management of mass-casualty incidents. 22,23 So, it is a critical component of the health systems and is necessary to improve outcomes of injuries and other timesensitive illnesses. 24 To inform the stakeholders for effective policy and program interventions improving the existing prehospital emergency service system, it is essential to gain a deeper understanding of the various domains within the system, such as response time, patient safety, resource utilization, quality of information exchange, and transportation care in resource-poor settings.
There exists a need for a comprehensive assessment of the situation of the prehospital care system in LMICs, as there are few studies conducted in this area. This review can provide insights into the challenges and opportunities for improving emergency care in LMICs.

Aim
This systematic review aimed to assess the prehospital emergency care system in LMICs with special emphasis on the structure of an EMS system, transport care, prehospital time interval, communication exchange, and patient satisfaction.

Protocol
The protocol for this systematic review has been published in the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (S1 Table; available online only). 25 Search Strategy and Selection Criteria Four electronic databases were systematically searched: PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA), EMBASE (Elsevier; Amsterdam, Netherlands), and SCOPUS (Elsevier; Amsterdam, Netherlands), for published reports of prehospital emergencies in LMICs using database-tailored search strategy. Boolean logic was used in the databases with search terms including: "pre-hospital emergency," "Pre-hospital care," "emergency transport," and the names of LMICs. A manual search was also performed in the reference lists of the included studies and systematic reviews on similar topics identified in the database search. Studies published from January 1, 2010 through November 1, 2022 were eligible for selection in the review.
The studies retrieved through database search were imported to Zotero citation manager (Version 6.0.26; Corporation for Digital Scholarship; Vienna, Virginia USA). After eliminating duplicate articles in Zotero, reviewers independently performed basic screening (title/abstract) of studies based on the eligibility criteria to proceed to the next step of the screening.

Criteria for Study Selection
Inclusion-Inclusion criteria were as follows: • Studies assessing the quality or status of prehospital emergency care in at least one of the LMICs based on the World Bank's (Washington, DC USA) classification. 26 • Qualitative and quantitative studies published in English language. • Studies reporting on the six different areas of prehospital emergency care: prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were included in this review.
Exclusion-Letters to the editor, review articles, and studies published in languages other than English were excluded. Studies that focused on intra-hospital emergency health care or intrahospital patient transportation were also excluded from the review.

Data Extraction
Authors individually extracted data from the included studies using a data extraction

Assessment of Risk of Bias
Authors HKB and SB independently assessed the potential risk of bias in the included studies using the Newcastle-Ottawa quality assessment scale (NOS). 27 This scale assesses the quality of the articles in the domains of selection, comparability, and exposure. The maximum score on the NOS was eight. Studies that scored more than six points were considered of high quality, studies scoring four-to-six points were considered moderate quality, and studies with scores less than four points were considered as being of low methodological quality. 28,29 The Critical Appraisal Skills Programme (CASP) checklist was used to appraise the health-related qualitative evidence syntheses. 30 The CASP tool has ten questions across three main areas: internal validity, results, and external validity. Each question on the checklist is scored as either "yes," "no," or "cannot tell."

Study Selection
The search strategy yielded 4,909 citations from four databases. After duplicate removal, a total of 3,876 studies were retrieved for the title and abstract screening, of which 213 studies were selected for full-text screening. After the full-text screening, 126 studies were excluded for the following reasons: wrong outcome, wrong study design, wrong study period, not conducted in LMICs, fulltext not found, and wrong study setting. Therefore, a total of 87 studies met the inclusion criteria and were included in this review, as depicted in Figure 1 using the PRISMA diagram.
The studies included different cases of prehospital emergencies. Overall, among the 87 studies included in the review, trauma and injuries (n = 40) were the major emergency conditions requiring prehospital care. Other studies included emergencies of chronic diseases (n = 21), disasters (n = 7), pediatrics (n = 4), obstetrics (n = 4), and other conditions (n = 11).
The outcomes were categorized into six major categories: prehospital emergency care structure (n = 26 studies), transport care (n = 26 studies), prehospital times (n = 22 studies), health outcomes (n = 18 studies), quality of information exchange (n = 4 studies), and patient satisfaction (n = 3 studies). Some of the studies reported multiple outcomes, therefore, the total number exceeded 87.

Methodological Quality
The individual scores ranged from three-to-eight for crosssectional studies on the NOS. Twenty of the studies were classified as being of high methodological quality, 41 were appraised as being of moderate quality, and two were classified as low quality. For the cohort studies, the individual scores ranged from four-to-eight points. Four of the studies were classified as being of high quality, and the remaining five were classified as having moderate methodological quality.
Qualitative studies were subject to quality assessment using the CASP checklist. Out of a total score of ten, eight studies received a score of ten, five studies received a score of nine, and two studies received a score of eight.

Status of Prehospital Emergency Care Services
Prehospital Emergency Care Structure-Twenty-seven studies assessed the prehospital emergency care structure in various countries and regions and identified a range of challenges and deficiencies. Prehospital emergency services provided in most areas were suboptimal. Several studies in South Africa, 31 Pakistan, 32 Malawi, 33 Iran, 34 Yemen, 35 and Peru 36 found uncoordinated, fragmented, and insufficient prehospital care systems. Another study in Iran by Bidgoli, et al showed an unequal distribution of prehospital trauma care facilities between provinces. 37 On the aspect of human resources, most of the patients were attended by members of the public as first responders. [38][39][40] Many studies highlighted a lack of trained medical personnel and first responders, which could lead to delays in providing care and poor outcomes for patients. 34,37,41,42 Insufficient multidisciplinary teams and poor infrastructure, including road access, lack of basic materials, and uncoordinated and fragmented system, were frequently cited as a challenge to the effective functioning of the prehospital care system. 36,[42][43][44][45] Five studies assessed prehospital care and preparedness plans during disasters. 44,[46][47][48][49] Issues like lack of a structured disaster management plan, absence of standardized medical teams, shortages of resources, lack of basic knowledge among rescue teams, and ineffective coordination were observed in the studies (Table 1 11,. Transport Care-Twenty-five studies reported a number of issues related to transport care regarding prehospital emergency care. Many studies found that patients were often transported by family members or private vehicles rather than ambulances. 8,10,[56][57][58] Patients in difficult terrains experienced delays in reaching health facilities. Also, there was a significant association of longer transport time to worse outcomes. 59,60 Studies have found that the use of automated external defibrillators (AEDs) and Advanced Life Support (ALS) interventions during ambulance transportation can improve patient outcomes. 59,61,62 However, the percentage of ambulances equipped with AEDs, ventilator, disposable splint, and wheelchair were very far from standards. 57,58,63 Only a minority of ambulances across LMICs were physicianstaffed or had Basic Life Support (BLS)-trained personnel. [64][65][66][67][68] A study conducted among cardiac emergency cases in Iran found a lower death rate when transported by EMS. 62 Similarly, a study in Turkey reported a higher short-term mortality rate among pediatric emergencies if the ambulance was staffed by only paramedics. 65 Overall, factors such as absence of dedicated vehicles, lack of equipment on ambulances, and lack of skilled personnel during transportation were major challenges for effective transport care during an emergency (Table 2 8 Studies conducted among trauma patients in India 39 and Ethiopia 38 showed that only 34.5% and 56.1%, respectively, were able to reach health facilities within the golden hour. A slightly higher proportion of patients were transported to the emergency centers (ECs) in Rwanda within the golden hour. 79 Studies have found that the use of specialized vehicles such as motorlances (motorcycles modified to be used as ambulances) and helicopter Emergency Medical Services (HEMS) can lead to shorter response times than traditional ambulances, 61,69,80 which was in turn associated with improved health outcomes and lower mortality. 59,81,82 Factors that affected response times included the distance from the hospital, location, type of emergency, and ambulance mechanism. Additionally, several studies found that response times in rural areas were generally longer than those in urban areas [83][84][85] (Table 3 38,39,59,61,63,69,74,[79][80][81][82][83][84][85][86][87][88][89][90][91][92][93] ).
Health Outcomes-Eighteen studies assessed health outcomes following prehospital emergency care. The studies reported that prehospital care interventions performed were associated with EMS personnel's skills and educational level. Prehospital systems of trained paramedics and layperson first responders reduced trauma mortality in severe RTA injuries. 94,95 Increasing prehospital time was associated with adverse outcomes and mortality among emergency cases. 81 Especially following cardiac emergencies like out-of-hospital cardiac arrest (OHCA), the survival rate was low. Factors like bystander cardiopulmonary resuscitation (CPR), public availability of AED, and public awareness of early cardiac arrest were more likely to increase the survival rate among cardiac emergencies and RTAs. 86,[96][97][98] Advanced transport systems like HEMS and Urgent Medical Aid Service (SAMU) have reduced transportation time and played a crucial role in reducing mortality. 80,99,100 A study conducted by Sobuwa, et al 101 showed that prehospital intubations performed among traumatic brain injury patients did not demonstrate improved outcomes, however, another study conducted in South Africa reported a 98% success rate of prehospital endotracheal intubation 102 (Table 4 80 Patient Satisfaction-Three studies reported on the satisfaction of patients regarding prehospital care and all were conducted in Iran. [109][110][111] Aboosalehi, et al 109 found that almost 80% of emergency patients were highly satisfied with the services provided by Tehran EMS. Also, high educational and economic status, proper sent vehicle, and accurate diagnosis were amongst the factors leading to higher satisfaction among patients. 109 Another study found that patient satisfaction with the dispatcher was   (Table 5 [109][110][111] ).
Quality of Information Exchange-Four studies assessed the quality of information exchange in the prehospital setting. It appeared that the quality of information exchange in the prehospital setting was an issue that needed to be addressed. Communication barriers between dispatch personnel and medical facilities/EMS personnel were deemed to be a high priority. 31 The dispatching unit personnel in prehospital emergency care were confronted with various interactional, organizational, and professional issues. 112 Also, inter-facility communication was found as poor in a study conducted in Ethiopia 113 (Table 6 31,[112][113][114] ).

Discussion
This systematic review assessed the prehospital emergency care services across LMICs. Different areas of prehospital care including the structure of a system, transport care, prehospital time interval, communication exchange, and patient satisfaction were explored. Most of the studies across LMICs reported the absence of a structured system for prehospital emergency care. For example, studies in South Africa, 31 Pakistan, 32 Yemen, 35 Iran, 34,35 and Peru 36 found uncoordinated and fragmented systems without proper protocols. Also, poor access, lack of infrastructure, lack of experienced and skilled EMS personnel, and poor communication, were among the major reasons behind ineffective prehospital care delivery in developing countries. 31,36,37,41,[43][44][45] In a few cases, the prehospital care system was well poised to meet the demand for prehospital emergency care and transport. Mould-Millman, et al 11 found that the National Ambulance Service (NAS) in a region of Ghana was well poised to meet the demand for prehospital emergency care and transport. 11 Similarly, a study in rural Uganda demonstrated an affordable and highly utilized, newly implemented EMS system. 50 Prehospital care may be neglected and less prioritized in LMICs. 115 These countries often have limited financial resources to invest in emergency care systems, which can lead to shortages of equipment, ambulances, and trained personnel. Additionally, developing countries nowadays are facing the double burden of communicable diseases and chronic diseases, so they may have to focus on primary health care and disease prevention rather than implementing and strengthening the EMS system. 116,117 The recent coronavirus disease 2019/COVID-19 pandemic also had an impact on the structure and functioning of the EMS systems. One of the main impacts has been the need to prioritize infection control measures to contain the virus which has resulted in changes to the way EMS operates, ultimately affecting the ability of EMS personnel to quickly and safely transport patients to hospitals. 118,119 Survival from severe injuries and time-sensitive illnesses is linked to the rapid initiation of treatment. This goal is achieved when a system of prehospital transportformal or informalis available to transport patients in the safest and fastest possible way to the nearest ECs. 58,120 Unfortunately, this essential component of effective emergency care is lacking in many LMICs; as a result, 90% of injury deaths occur in these countries. 121 A shortage of trained emergency personnel is another impediment to establishing a prehospital emergency response   system. Working as an emergency technician is one of the most stressful jobs, and the lack of additional compensation and incentives might have forced them to alter their job or attract newer ones to the job. 122 In resource-poor countries, involving and providing training to the community members and lay responders might have a meaningful impact on the emergency service. 51 Having trained paramedics or physicians with knowledge of BLS in an ambulance is important for prehospital care as it allows for prompt and appropriate treatment of patients in emergencies. 123 Trained personnel can provide life-saving interventions such as CPR, the use of an AEDs, and airway management, all of which can greatly improve a patient's chances of survival and recovery. 124,125 Studies in India, 66 Zambia, 58 and Vietnam 57 showed only 7.5%, 5.9%, and 20.0% of emergency patients were transported by public or private ambulances. Also, ambulances were often lacking life-saving interventions 57,63,69 and BLS-trained personnel. 56,[66][67][68] Efficient time management is one of the key mechanisms to reducing mortality in emergency patients, especially for trauma and injuries. It is widely accepted that if injured patients do not receive definitive care within the first 60 minutes, the golden hour, of injuries, the chance of mortality significantly increases. 126,127 A very low proportion of trauma patients in India and Ethiopia were transported to the nearest EC within the golden hour. 38,39 Prehospital partial time intervals such as response time, scene time, and transport time varied across the LMICs, which might have been greatly influenced by factors distinct from systems of EMS, such as traffic congestion or geographic factors that impede rapid transport.
Motorlances in Thailand showed shorter activation and response time compared to conventional ambulances. 69 Due to its small structure, it can easily pass through narrow passages/ roads, as well as being able to pass through gridlock traffic in confined areas. 128 Similarly, patients transported by Lagos State Ambulance Service (LASAMBUS) in Nigeria also had shorter arrival times. 8 The SAMU that dispatches a team of emergency medical personnel to the scene to provide on-site medical care and transports the patient to a hospital for further treatment was seen across different countries. Studies in Brazil 70,71 and Rwanda 72 showed a reduction in the underlying mortality rate since SAMU implementation. Similarly, National Emergency Medical Service (NEMS) in Sierra Leone enhanced access to hospital care among vulnerable rural populations by overcoming existing barriers such as geographical accessibility and transport availability. 73 Not having sufficient funds to purchase expensive medical equipment or train EMTs, inadequate regulations and lack of oversight, and poor communication or collaboration between different providers could be the major challenges to effective transport care in LMICs. Also, difficult terrain or geography and challenging weather can greatly affect prehospital transport, which is evident in the findings of studies conducted in Sierra Leone, 81 Iran, 85 and India. 84 Most of the studies suggested that the health outcome following prehospital care in LMICs is generally poor. Survival following cardiac emergencies like OHCA and severe trauma was low. [96][97][98] Some studies found improved outcomes when patients were provided with BLS measures and airway management in the prehospital setting. 96,101 Longer response time, unavailability of BLS measures like AED and CPR, and unskilled EMS personnel are the reasons for poor health outcomes following prehospital emergencies. Additionally, cultural and societal factors, such as lack of education about emergency care and limited trust in the health care systems, can also contribute to poor outcomes. 36,52 As prehospital care is provided outside of the hospital, a focus on both the administrative and programmatic aspects of health care delivery is required, which demands strong political commitment. 129 Poor commitment by decision makers at all levels of management is a repeatedly mentioned barrier to effective care delivery. 130 As there are many challenges to the prehospital system in the LMICs, there are also possible opportunities for improvement. Collaboration between different stakeholders, including governmental agencies, health care providers, civil society organizations, and international organizations, can leverage expertise, resources, and networks to improve prehospital care in poor-resource settings. Many studies have mentioned   The highest incidence of calls came from rural areas, however, the time to respond in rural areas was longer than that in urban areas. 19 Paravar, et al 2013 85 1,600 RTA cases; Cross-Sectional Moderate Iran Injuries The mean prehospital time intervals (minutes); response, scene, and transport for all patients 6.6 (SD = 3.1), 10.7 (SD = 5), and 13 (SD = 9.8), respectively.
Time intervals on roads out of the city were higher than those on city streets. 20 Paravar, et al 2014 59 2,000 trauma patients; Cross-Sectional Study High Iran Trauma The mean response time, at scene time, and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2), and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcomes.

Limitations
This systematic review has certain limitations. There might be some improvements in the EMS during the study period (January 1, 2010 through November 1, 2022), and thus these situations might have changed. As the results were not retrieved from all LMICs, the findings are limited to those nations for which references were retrieved. Moreover, only English and peerreviewed articles were sought, and the gray literature was not taken into consideration. The inclusion criteria were broad, which could have led to the inclusion of heterogeneous outcomes. Despite a few limitations, this study made a comprehensive assessment of different domains of prehospital care in LMICs. A range of challenges and barriers were identified in the system, which could be advantageous in designing and implementing policies for the proper functioning and strengthening of the prehospital system in LMICs.

Conclusion
The implementation and situation of a prehospital emergency care system varied across LMICs. Overall, most LMICs lack an organized prehospital care system and are relatively far from the acceptable standard. Further, the lack of trained medical personnel and first responders, poor infrastructure, lack of basic materials, and inadequate transport care are the key challenges.   Overall, stakeholders should focus on developing and implementing emergency care guidelines and protocols that are tailored to the specific needs of their countries. In addition to this, increasing resources for emergency care, investing in training for EMS personnel, improving infrastructure, and establishing a coordinated system for emergency care to improve communication and coordination should be the priority for concerned stakeholders.

Supplementary Materials
To view supplementary material for this article, please visit https:// doi.org/10.1017/S1049023X23006088