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

Improving Perioperative Mortality Rate Data Capture in Hawassa, Ethiopia: A Mixed-Methods Study

BACKGROUND

In 2015, Ethiopia created a national strategic plan aimed at increasing surgical capacity. This encompassed a set of surgical indicators collected at each hospital, which facilitates assessment of the current state of surgical practices and enables monitoring of progress towards improving outcomes. This project aimed to investigate one of these key surgical indicators, the perioperative mortality rate (POMR), in the largest referral hospital in the Sidama region.

METHODS

Perioperative mortality was defined as death after major surgery prior to hospital discharge. The number of surgical deaths and surgical volume for the most recent reporting year (July 2022-May 2023) were extracted from registries and discharge information. POMR was compared between the following data sources: (1) paper registries from the operating rooms, surgical wards, ICU, (2) aggregate discharge information from the Liaison Office, (3) monthly indicator reports to the health management information system (HMIS), and (4) reports on the national data collection system (DHIS2). Additionally, qualitative interviews with healthcare professionals and data officers were conducted to evaluate current practices and challenges in collecting POMR.

RESULTS

The aggregate reported 1-year POMR was 0.9% (56/6438) for registries, 0.9% (57/6336) for discharge information, 0.5% (33/6437) for HMIS reports, and 0.6% (35/5935) for DHIS2 reports. Qualitative interviews (n = 17) reported regular tracking of perioperative deaths within surgical departments and surgical data quality checks by quality officers. However, many interviewees identified the lack of an electronic system as a significant barrier to accurate, timely data collection. Other proposed solutions include implementing closer monitoring of data quality, providing additional equipment and training for staff on data entry, and promoting timely completion of monthly reports.

CONCLUSION

Explanations behind the discrepancies in POMR between data sources in this study include inconsistencies in data entry, lack of consolidation of postoperative deaths from different service points (wards, ICU), and reports generated without a mechanism to include updated registry or discharge counts. These findings, along with the diverse perspectives from our interviews, point toward the need for a well-trained workforce and the development of a digital record system to improve POMR data capture.

Quality Improvement in Rural and Low-Resource Settings

Access to surgical care is a critical determinate of health outcomes yet disparities persist across various populations, particularly in low-resource settings (LRS). Quality improvement (QI) has become an integral component of health care optimization in such areas. The challenges of health care delivery in LRS directly translate into common barriers in QI endeavors such as the need for adequate funding, personnel trained in QI processes, and appropriate systems for consistent data collection. Many initiatives have been developed to address the multifaceted barriers in accessing surgical services and to improve patient safety and the quality of surgical care in LRS. Multiple studies have highlighted successful QI projects including implementing checklists to reduce surgical site infections, augmenting patient and staff education to reduce postoperative readmission rates, and adapting telemedicine in virtual intensive care units in rural areas. As new solutions, frameworks, and literature on QI initiatives expand, opportunities to enhance surgical care in LRS are becoming more apparent. This manuscript will review multiple aspects of QI including methods used in health care, barriers frequently encountered, challenges unique to LRS as well as projects implemented in LRS, with the goal of helping underserved health care settings learn and implement quality initiatives to improve the delivery of surgical care.

Pitfalls and Strategies for Implementing and Sustaining an Otolaryngology Perioperative Registry in Mekelle, Ethiopia

BACKGROUND

Surgical registries have been widely adopted in high-income countries to improve patient outcomes. However, similar data-driven initiatives are still scarce in low- and middle-income countries (LMICs).

AIMS

This study aimed to address the challenges of implementing a perioperative registry for otolaryngology-head and neck surgery (OHNS) in Mekelle, Ethiopia, and to assess strategies for ensuring its long-term sustainability.

METHODS

The registry was developed using REDCap, through a collaborative effort between otolaryngologists in the United States and Ethiopia, ensuring its relevance to the local context. On-site training sessions were conducted for 13 OHNS residents and four senior surgeons to facilitate their use of the registry. A Wi-Fi router was installed in the operating room to enable real-time data entry. Continuous support was provided through remote communication between the local team and the U.S. research team. Sustainability strategies focused on fostering local ownership, integrating the registry into existing workflows, and maintaining continuous data monitoring.

RESULTS

Despite facing challenges like intermittent internet connectivity and issues with workflow integration, the local team successfully integrated the registry into routine clinical and surgical practices. Key strategies included providing dedicated Wi-Fi routers, modifying registry fields for improved efficiency, and emphasizing the registry's value to the institution. Ongoing collaboration between the local team and the U.S. team enabled continuous optimization and data collection.

CONCLUSION

The successful implementation of this perioperative registry underscores the importance of engaging local stakeholders and integrating sustainable workflows. This initiative serves as a model for other LMICs seeking to establish surgical registries that enhance data-driven decision-making at both the patient and institutional levels.

Surgical Practice in Resource-Limited Settings: Perspectives of Medical Students and Early Career Doctors: A Narrative Review

Introduction

Surgical practices in low-resource countries often fail to meet established standards. Both doctors and medical students have limited exposure to surgical cases, which hinders training and the development of surgical specialization. This study highlights the current state of surgical practice from a trainee's perspective, explores existing gaps in training and capacity building, and recommends practical solutions.

Methods

We conducted a literature search on PubMed, Google Scholar, and other scientific databases using search terms such as "surgical practice," "doctors' perspectives in surgical practice," "surgery in low- and middle-income countries," and "solutions to surgical inadequacy." We included studies published from 2015 to 2024, with exceptions for a few highly relevant studies published prior to 2015.

Results

We outline the limitations identified in the literature concerning surgical training and healthcare in low- and middle-income countries. Many centers lack adequate infrastructure, human resources, and training. These challenges negatively affect the skills and quality of surgical care. However, some centers demonstrate that surgical practice is feasible through collaboration with institutions established in higher-income contexts.

Conclusion

Telesurgery, task shifting and sharing, high-impact, low-cost surgeries, and collaborations with more developed health systems could effectively bridge the gap in surgical availability in LMICs.

Barriers to Research Faced by High-Income Versus Low- and Middle-Income Country Otolaryngologists and Otolaryngology Residents

Objective

This study aims to compare research productivity and barriers to research between high-income countries (HICs) and low- and middle-income countries (LMICs) otolaryngologists.

Study Design

Cross-sectional survey.

Setting

International survey.

Methods

A survey developed by members of the Lebanese Otolaryngology Research and Awareness Group was disseminated globally to otolaryngologists and otolaryngology residents. The survey assessed research efficiency, funding, and perceived barriers. Data were analyzed using t tests and χ 2 tests.

Results

A total of 82 responses from 21 countries were recorded, with 33 from HICs (40.2%) and 49 from LMICs (59.8%). LMIC respondents reported significantly less research funding (84.4% vs 60.6%, P = .013) and fewer publications (24.4% vs 3.1%, P = .001) compared to HIC respondents. LMICs faced unique individual barriers like elderly care responsibilities (17.8% vs 0%, P = .035). Organizational challenges in LMICs included limited access to information sources (35.7% vs 15.6%, P = .017) and financial resources (85.7% vs 40.6%, P < .001). Institutional challenges such as lack of funding (83.3% vs 34.4%, P < .001) and protected research time (71.4% vs 56.3%, P = .047) were more prominent in LMICs. Governmental barriers were also greater in LMICs, including demotivating government policies (59.0% vs 9.4%, P < .001). Additionally, covering article processing charges was a significant challenge for 76.2% of LMIC respondents compared to 31.3% in HICs (P = .001).

Conclusion

Otolaryngologists in LMICs encounter substantial barriers to research productivity compared to those in HICs, primarily due to funding gaps, lack of institutional support, and unfavorable governmental policies. Addressing these disparities is essential for fostering equitable global research contributions.

Voices From the Frontline: A Reflexive Thematic Analysis Illuminating Perioperative Practice Realities in Southern Ethiopian Teaching Hospitals

Despite national efforts, gaps persist in Ethiopian perioperative care. This reflexive thematic analysis aimed to investigate the contextual challenges faced in delivering perioperative care. In-depth interviews were conducted with 20 healthcare professionals, including anesthetists, nurses, and surgeons, to gain a frontline perspective of perioperative practice realities. The analysis revealed eight interconnected themes: systemic infrastructure vulnerabilities, workforce expansion uncertainties, workforce demoralization, fragile perioperative safety culture, hierarchical structures and communication barriers, financial barriers to care, fragmented information systems, and fragile governance with sociopolitical instability. Local deficiencies in resources and equipment were amplified by global challenges, creating a precarious care environment. While workforce numbers increased, concerns persisted about competency and training quality. Systemic pressures and unmet professional needs contributed to staff demoralization. Inconsistent safety practices and top-down quality improvement initiatives hindered sustainable progress. Rigid hierarchies and departmental silos impeded effective teamwork and resource coordination. Financial constraints created significant barriers to care access and ethical dilemmas for providers. Incomplete digitalization and inconsistent documentation practices compromised continuity of care and data-driven improvements. Overarching sociopolitical instability and weak governance cascaded into healthcare system disruptions. The findings underscore the need for a multifaceted approach to strengthen perioperative care, including improving infrastructure, enhancing workforce development, fostering a culture of safety, breaking down hierarchical barriers, addressing financial accessibility, implementing robust information systems, and building resilient governance structures amidst adversity.

Use of industrial liquid silicone: a scoping review

PURPOSE

Illicit cosmetic injections remain highly prevalent and can cause serious complications, including death. We aimed to explore existing literature regarding the use of illicit cosmetic injections globally.

METHODS

We searched six databases with no language restriction from inception to 2022. We included all articles focused on adult patients of any gender who received any illicit cosmetic injection. Screening and data extraction followed standards from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews guidelines.

RESULTS

After screening 629 abstracts and 193 full texts, 142 citations were included. We identified articles from 28 countries and three multi-country studies. Most were from high-income (75.3%) and upper-middle-income countries (21.8%). Of all patients whose gender identity was described, 49.9% were transgender women, and 40.8% were cisgender women. The anatomic regions most frequently injected were the buttocks (35%) and the breast (13.3%). The most frequently described complications were granuloma (41.5%), dermatological problems (41.5%), infection (35.9%), and pulmonary complications (34.5%).

CONCLUSIONS

We observed the impact of illicit silicone injections, particularly on cisgender women and transgender individuals. Existing barriers must be addressed, including healthcare prejudice and inadequate knowledge about care for gender minorities. This will require educating at-risk groups and enhancing policies to regulate these procedures.

Fidelity in Academic Global Surgery and Research: Incorporating Trustworthiness in the Development of Research Partnerships, Infrastructure, and Policy

Academic global surgery consists of collaborative partnerships that address surgical inequities through research, training, education, advocacy, and diplomacy. It has been characterized by increased scholastic production through global surgery publications, dedicated global surgery sessions within scientific conferences, global surgery-specific research grants, database development to support global surgery research, global surgery research fellowships, and global surgery-based academic promotion paradigms. The increased emphasis on global surgery research has been accompanied by multiple ethical challenges. This article reviews critical ethical dilemmas presented by global surgery research efforts and proposes interventions on the partnership, infrastructural, and policy levels to enhance fidelity within research partnerships.

Implementation of a perioperative registry in Ethiopia to enhance surgical quality improvement

BACKGROUND

Despite a glaring need and proven efficacy, prospective surgical registries are lacking in low- and middle-income countries. The objective of this study was to design and implement a comprehensive prospective perioperative registry in a low-income country.

METHODS

This study was conducted at Hawassa University Comprehensive Specialized Hospital in Hawassa, Ethiopia. Design of the registry occurred from June 2021 to May 2022 and pilot implementation from May 2022 to May 2023. All patients undergoing elective or emergent general surgery were included. Following one year, operability and fidelity of the registry were analyzed by assessing capture rate, incidence of missing data, and accuracy.

RESULTS

A total of 67 variables were included in the registry including demographics, preoperative, operative, post-operative, and 30-day data. Of 440 eligible patients, 226 (51.4%) were successfully captured. Overall incidence of missing data and accuracy was 5.4% and 90.2% respectively. Post pilot modifications enhanced capture rate to 70.5% and further optimized data collection processes.

CONCLUSION

The establishment of a low-cost electronic prospective perioperative registry in a low-income country represents a significant step forward in enhancing surgical care in under-resourced settings. The initial success of this registry highlights the feasibility of such endeavors when strong partnerships and local context are at the center of implementation. Continuous efforts to refine this registry are ongoing, which will ultimately lead to enhanced surgical quality, research output, and expansion to other sites.

Perioperative capacity and contextual challenges in teaching hospitals of southern Ethiopia: explanatory sequential mixed-methods research

BACKGROUND

Previous Ethiopian literature on surgical capacity and challenges has focused on quantitative investigations, lacking contextual understanding. This explanatory sequential mixed-methods research (MMR) aimed to assess perioperative capacity and contextual challenges at three teaching hospitals in southern Ethiopia.

METHODS

A quantitative survey assessed workforce, infrastructure, service delivery, financing, and information systems. The survey findings were explained by qualitative semi-structured interviews of twenty perioperative providers. Descriptive statistics were integrated with qualitative thematic analysis findings using the narrative waving approach. Key findings from both datasets were linked using a joint display table.

RESULTS

The survey revealed shortages in the specialist workforce (with a ratio of 0.58 per 100,000 population), surgical volume (at 115 surgeries per 100,000 population), equipment, supplies, financing, and perioperative data tracking. Hospitals' radiology services and blood products were only available 25-50% of the time, while anesthetic agents and essential laboratory services were often available 51-75% of the time. Perioperative management protocols were used rarely (1-25% of the time). Over 90% of patients lack health insurance coverage. Qualitative data also revealed scarcity of perioperative resources and equipment; unaffordable perioperative costs, lack of health insurance coverage, and unforeseen expenses; poor patient safety culture and communication barriers across the perioperative continuum of care; workforce shortages, job dissatisfaction, and concerns of competence; and weak national governance, and sociopolitical turmoil, and global market volatility exacerbating local challenges. These challenges are linked to risks in quality of care and patient safety, according to clinicians.

CONCLUSION

The study identifies deficiencies in the health system and sociopolitical landscape affecting safe surgery conduct. It highlights the need for comprehensive health system strengthening to expand workforce, upgrade facilities, improve safety culture, resilience, and leadership to ensure timely access to essential surgery. Exploring external factors, such as the impact of national governance and sociopolitical stability on reform efforts is also essential.

Barriers and Challenges to Implementing a Quality Improvement Program: Political and Administrative Challenges

Quality improvement (QI) programs have rapidly grown in health care over recent years. Despite increasing evidence of successful QI initiatives resulting in improved outcomes, the adoption and implementation of QI programs remain a challenge worldwide. This paper briefly describes political and administrative barriers that impede the implementation of QI programs, including political and ideological factors, socioeconomic and educational barriers, and barriers related to data collection, privacy, and security. Key political and administrative barriers identified include resource limitations due to inadequate public funding, stringent laws, and change resistance. Potential solutions include support and commitment from regional and national authorities, consultation of all involved parties during QI program development, and financial incentives. The barrier of limited resources is starker among low- and middle-income countries (LMICs) compared with high-income countries (HICs) due to the absence of adequate infrastructure, personnel equipped with QI-oriented skills, and analytical technology. Solutions that have facilitated QI programs in some LMICs include outreach and collaboration with other health centers and established QI programs in HICs. The lack of QI-specific training and education in medical curricula challenges QI implementation but can be mitigated through the provision of QI promotion webinars, QI-specific project opportunities, and formalized QI training modules. Finally, barriers related to data collection, privacy, and security include laws hindering the availability of quality data, inefficient data collection and processes, and outdated clinical information systems. Access to high-quality data, organized record-keeping, and alignment of data collection processes will help alleviate these barriers to QI program implementation. The multidimensional nature of these barriers means that proposed solutions will require coordination from multiple stakeholders, government support, and leaders across multiple fields.

Patient-Centered Surgical Care for Children in Low and Lower-Middle Income Countries (LMICs) - A Systematic Scoping Review of the Literature

PURPOSE

Studies exploring patient-centered care (PCC) in pediatric surgery have been disproportionately concentrated in high-income countries. This review aims to characterize the adoption of key PCC domains in low and lower-middle income countries (LMICs).

METHODS

Seven databases were searched from inception until January 2023 to retrieve relevant articles in pediatric surgery in LMICs. We focused on six key PCC domains: patient-reported outcomes (PROs), patient-reported experiences (PREs), shared decision-making (SDM), patient/parent education, patient/parent satisfaction, and informed consent.

RESULTS

Of 8050 studies screened, 230 underwent full-text review, and 48 were finally included. Most were single-center (87.5%), cross-sectional studies (41.7%) from the South-East Asian (35.4%) and Eastern Mediterranean regions (33.3%). Studies most frequently focused on postoperative care (45.8%) in pediatric general surgery (18.8%), and included 1-3 PCC domains. PREs (n = 30), PROs (n = 16) and patient/parent satisfaction (n = 16) were most common. Informed consent (n = 2) and SDM (n = 1) were least studied. Only 13 studies directly elicited children's perspectives. Despite all studies originating in LMICs, 25% of first and 17.8% of senior authors lacked LMIC affiliations.

CONCLUSION

The adoption of PCC in LMICs appears limited, focusing predominantly on PROs and PREs. Other domains such as informed consent and SDM are rarely addressed, and the voice of children and young people is rarely heard in their care. Opportunities to enhance PCC in LMICs abound, with the potential to improve the surgical care of children in resource-limited settings.

LEVEL OF EVIDENCE

III.

Barriers and Facilitators to Collecting Surgical Outcome Data in Low- and Middle-Income Countries: An International Survey

Background

Perioperative data are essential to improve the safety of surgical care. However, surgical outcome research (SOR) from low- and middle-income countries (LMICs) is disproportionately sparse. We aimed to assess practices, barriers, facilitators, and perceptions influencing the collection and use of surgical outcome data (SOD) in LMICs.

Methods

An internet-based survey was developed and disseminated to stakeholders involved in the care of surgical patients in LMICs. The Performance of Routine Information Systems Management framework was used to explore the frequency and relative importance of organizational, technical, and behavioral barriers. Associations were determined using χ 2 and ANOVA analyses.

Results

Final analysis included 229 surgeons, anesthesia providers, nurses, and administrators from 36 separate LMICs. A total of 58.1% of individuals reported that their institution had experience with collection of SOD and 73% of these reported a positive impact on patient care. Mentorship and research training was available in <50% of respondent's institutions; however, those who had these were more likely to publish SOD (P = 0.02). Sixteen barriers met the threshold for significance of which the top 3 were the burden of clinical responsibility, research costs, and accuracy of medical documentation. The most frequently proposed solutions were the availability of an electronic data collection platform (95.3%), dedicated research personnel (93.2%), and access to research training (93.2%).

Conclusions

There are several barriers and facilitators to collection of SOD that are common across LMICs. Most of these can be addressed through targeted interventions and are highlighted in this study. We provide a path towards advancing SOR in LMICs.