Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania

Barriers to Surgical Outcomes Research in Low- and Middle-Income Countries: A Scoping Review

INTRODUCTION

Systematic collection and analysis of surgical outcomes data is a cornerstone of surgical quality improvement. Unfortunately, there remains a dearth of surgical outcomes data from low- and middle-income countries (LMICs). To improve surgical outcomes in LMICs, it is essential to have the ability to collect, analyze, and report risk-adjusted postoperative morbidity and mortality data. This study aimed to review the barriers and challenges to developing perioperative registries in LMIC settings.

METHODS

We conducted a scoping review of all published literature on barriers to conducting surgical outcomes research in LMICs using PubMed, Embase, Scopus, and GoogleScholar. Keywords included 'surgery', 'outcomes research', 'registries', 'barriers', and synonymous Medical Subject Headings derivatives. Articles found were subsequently reference-mined. All relevant original research and reviews published between 2000 and 2021 were included. The performance of routine information system management framework was used to organize identified barriers into technical, organizational, or behavioral factors.

RESULTS

Twelve articles were identified in our search. Ten articles focused specifically on the creation, success, and obstacles faced during the implementation of trauma registries. Technical factors reported by 50% of the articles included limited access to a digital platform for data entry, lack of standardization of forms, and complexity of said forms. 91.7% articles mentioned organizational factors, including the availability of resources, financial constraints, human resources, and lack of consistent electricity. Behavioral factors highlighted by 66.6% of the studies included lack of team commitment, job constraints, and clinical burden, which contributed to poor compliance and dwindling data collection over time.

CONCLUSIONS

There is a paucity of published literature on barriers to developing and maintaining perioperative registries in LMICs. There is an immediate need to study and understand barriers and facilitators to the continuous collection of surgical outcomes in LMICs.

Online Health Communities: an alternative feasible data registry tool for developing countries

Given the many challenges facing healthcare access in many developing countries and the added limitations observed in emergencies like COVID-19 pandemic, the authors here discuss an alternative and feasible approach to overcome all these limitations.

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation across country income levels: a scoping review

OBJECTIVE

Trauma is a leading cause of mortality and morbidity globally, disproportionately affecting low/middle-income countries (LMICs). Understanding the factors determining implementation success for in-hospital Trauma Quality Improvement Programs (TQIPs) is critical to reducing the global trauma burden. We synthesised topical literature to identify key facilitators and barriers to in-hospital TQIP implementation across country income levels.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Web of Science and Global Index Medicus databases were searched from June 2009 to January 2022.

ELIGIBILITY CRITERIA

Published literature involving any study design, written in English and evaluating any implemented in-hospital quality improvement programme in trauma populations worldwide. Literature that was non-English, unpublished and involved non-hospital TQIPs was excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers completed a three-stage screening process using Covidence, with any discrepancies resolved through a third reviewer. Content analysis using the Consolidated Framework for Implementation Research identified facilitator and barrier themes for in-hospital TQIP implementation.

RESULTS

Twenty-eight studies met the eligibility criteria from 3923 studies identified. The most discussed in-hospital TQIPs in included literature were trauma registries. Facilitators and barriers were similar across all country income levels. The main facilitator themes identified were the prioritisation of staff education and training, strengthening stakeholder dialogue and providing standardised best-practice guidelines. The key barrier theme identified in LMICs was poor data quality, while high-income countries (HICs) had reduced communication across professional hierarchies.

CONCLUSIONS

Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus of trauma care best practices, are essential efforts to reduce the global trauma burden. The primary focus of future studies on in-hospital TQIPs in LMICs should target improving registry data quality, while interventions in HICs should target strengthening communication channels between healthcare professionals.

The epidemiology and characteristics of injuries to under 5's in a secondary city in Uganda: a retrospective review of hospital data

Child injuries are largely preventable yet cause significant mortality and morbidity globally. Injury data from low-income countries is limited for children under the age of 5 and therefore the current understanding of the magnitude of injuries in this age group is low. Hospital-based registries are one mechanism by which injury data can be gathered. This paper presents findings from a retrospective hospital record review of 4 hospitals in Jinja, a rural setting in Uganda, involving the extraction of data for children under the age of 5-years who sustained an injury during a 6-month period in 2019. A total of 225 injury cases were retrieved from the hospitals. Over half (57.3%) of the events occurred among males. The majority (92%) suffered one injury per injury event. Most of the injuries occurred among those aged 13 to 24 months (32.9%). Burns (32%) and cuts (20%) were the most common cause of injury. This study presents a hospital-based analysis of injuries amongst under 5's in rural Uganda. It provides information on the characteristics of children entering healthcare facilities in Uganda and highlights the burden of paediatric injuries in the hospital setting.

Barriers and facilitators to the conduct of critical care research in low and lower-middle income countries: A scoping review

Background

Improvements in health-related outcomes for critically ill adults in low and lower-middle income countries need systematic investments in research capacity and infrastructure. High-quality research has been shown to strengthen health systems; yet, research contributions from these regions remain negligible or absent. We undertook a scoping review to describe barriers and facilitators for the conduct of critical care research.

Methods

We searched MEDLINE and EMBASE up to December 2021 using a strategy that combined keyword and controlled vocabulary terms. We included original studies that reported on barriers or facilitators to the conduct of critical care research in these settings. Two reviewers independently reviewed titles and abstracts, and where necessary, the full-text to select eligible studies. For each study, reviewers independently extracted data using a standardized data extraction form. Barriers and facilitators were classified along the lines of a previous review and based on additional themes that emerged. Study quality was assessed using appropriate tools.

Results

We identified 2693 citations, evaluated 49 studies and identified 6 for inclusion. Of the included studies, four were qualitative, one was a cross-sectional survey and one was reported as an ‘analysis’. The total number of participants ranged from 20–100 and included physicians, nurses, allied healthcare workers and researchers. Barriers identified included limited funding, poor institutional & national investment, inadequate access to mentors, absence of training in research methods, limited research support staff, and absence of statistical support. Our review identified potential solutions such as developing a mentorship network, streamlining of regulatory processes, implementing a centralized institutional research agenda, developing a core-outcome dataset and enhancing access to low-cost technology.

Conclusion

Our scoping review highlights important barriers to the conduct of critical care research in low and lower-middle income countries, identifies potential solutions, and informs researchers, policymakers and governments on the steps necessary for strengthening research systems.

Barriers and facilitators for the implementation of health condition and outcome registry systems: a systematic literature review

OBJECTIVE

Health condition and outcome registry systems (registries) are used to collect data related to diseases and other health-related outcomes in specific populations. The implementation of these programs encounters various barriers and facilitators. Therefore, the present review aimed to identify and classify these barriers and facilitators.

MATERIALS AND METHODS

Some databases, including PubMed, Embase, ISI Web of Sciences, Cochrane Library, Scopus, Ovid, ProQuest, and Google Scholar, were searched using related keywords. Thereafter, based on the inclusion and exclusion criteria, the required data were collected using a data extraction form and then analyzed by the content analysis method. The obtained data were analyzed separately for research and review studies, and the developed and developing countries were compared.

RESULTS

Forty-five studies were reviewed and 175 unique codes were identified, among which 93 barriers and 82 facilitators were identified. Afterward, these factors were classified into the following 7 categories: barriers/facilitators to management and data management, poor/improved collaborations, technological constraints/appropriateness, barriers/facilitators to legal and regulatory factors, considerations/facilitators related to diseases, and poor/improved patients' participation. Although many of these factors have been more cited in the literature related to the developing countries, they were found to be common in both developed and developing countries.

CONCLUSION

Lack of budget, poor performance of managers, low data quality, and low stakeholders' interest/motivation on one hand, and financing, providing adequate training, ensuring data quality, and appropriate data collection on the other hand were found as the most common barriers or facilitators for the success of the registry implementation.

'I haven't heard much about other methods': quality of care and person-centredness in a programme to promote the postpartum intrauterine device in Tanzania

BACKGROUND

Programmes promoting the postpartum intrauterine device (PPIUD) have proliferated throughout South Asia and sub-Saharan Africa in recent years, with proponents touting this long-acting reversible contraceptive (LARC) method's high efficacy and potential to meet contraceptive unmet need. While critiques of LARC-first programming abound in the Global North, there have been few studies of the impact of LARC-centric programmes on patient-centred outcomes in the Global South.

METHODS

Here, we explore the impact of a PPIUD intervention at five Tanzanian hospitals and their surrounding satellite clinics on quality of contraceptive counselling and person-centred care using 20 qualitative in-depth interviews with pregnant women seeking antenatal care at one of those clinics. Using a modified version of the contraceptive counselling quality framework elaborated by Holt and colleagues, we blend deductive analysis with an inductive approach based on open coding and thematic analysis.

RESULTS

Interpersonal aspects of relationship building during counselling were strong, but a mix of PPIUD intervention-related factors and structural issues rendered most other aspects of counselling quality low. The intervention led providers to emphasise the advantages of the IUD through biased counselling, and to de-emphasise the suitability of other contraceptive methods. Respondents reported being counselled only about the IUD and no other methods, while other respondents reported that other methods were mentioned but disparaged by providers in relation to the IUD. A lack of trained providers meant that most counselling took place in large groups, resulting in providers' inability to conduct needs assessments or tailor information to women's individual situations.

DISCUSSION

As implemented, LARC-centric programmes like this PPIUD intervention may decrease access to person-centred contraceptive counselling and to accurate information about a broad range of contraceptive methods. A shift away from emphasising LARC methods to more comprehensive, person-centred contraceptive counselling is critical to promote contraceptive autonomy.

Development and pilot implementation of a standardised trauma documentation form to inform a national trauma registry in a low-resource setting: lessons from Tanzania

OBJECTIVES

Trauma registries are an integral part of a well-organised trauma system. Tanzania, like many low and middle-income countries, does not have a trauma registry. We describe the development, structure, implementation and impact of a context appropriate standardised trauma form based on the adaptation of the WHO Data Set for Injury (DSI), for clinical documentation and use in a national trauma registry.

SETTING

Our study was conducted in emergency units of five regional referral hospitals in Tanzania.

PROCEDURES

Mixed methods participatory action research was employed. After an assessment of baseline trauma documentation, we conducted semi-structured interviews with a purposefully selected sample of 33 healthcare providers from all participating hospitals to understand, develop, pilot and implement a standardised trauma form. We compared the number and types of variables captured before and after the form was implemented.

OUTCOMES

Change in proportion of variables of DSI captured after implementation of a standardised trauma documentation form.

RESULTS

Piloting and feedback informed the development of a context appropriate standardised trauma documentation paper form with carbonless copy that could be used as both the clinical chart and data capture. Among 721 patients (seen by 21 clinicians) during the initial 30-day pilot, overall variable capture was 86.4% of required variables. After modifications of the form and training of healthcare providers, the form was implemented for 7 months, during which the capture improved to 96.3% among 6302 patients (seen by 31 clinicians). The providers reported the form was user-friendly, resulted in less time documenting, and served as a guide to managing trauma patients.

CONCLUSIONS

The development and implementation of a contextually appropriate, standardised trauma form were successful, yielding increased capture rates of injury variables. This system will facilitate expansion of the trauma registry across the country and inform similar initiatives in Sub-Saharan Africa.