Reasons for not seeking formal healthcare after injuries: a qualitative study with injured individuals in four low- and middle-income countries

Injuries are a major cause of morbidity and mortality in low- and middle-income countries, but many individuals do not seek care within formal healthcare systems. Although previous studies have highlighted barriers to healthcare, limited attention has been given to the experiences of those who remain beyond the formal systems. This study explored why injured individuals in Ghana, Pakistan, Rwanda and South Africa did not seek hospital care. Ninety-seven participants were purposively sampled from rural and urban settings. Interview data were analysed thematically, drawing on biosocial and pluralistic understandings of care. Across countries and settings, participants described how decisions not to seek care were influenced by the combined effects of out-of-pocket costs, transport challenges, past experiences with providers and long waiting times. These factors interacted with sociocultural factors, including beliefs, family influences and trust in indigenous healers. However, formal healthcare was not entirely rejected. Rather, care seeking was dynamic and contingent, with participants navigating decision-making based on affordability, perceived effectiveness and acceptability of treatment. The findings highlight that seeking care for injury should be understood within broader structural and sociocultural contexts. Improving access to formal injury care requires contextually grounded, culturally responsive approaches that acknowledge pluralistic care practices and reflect lived experiences of injury.