In the world today, two out of every three people lack access to essential or emergency surgical care. Compared with high-income countries (HICs), surgery in low- and middle-income countries (LMICs) is generally of inferior quality and surgical outcomes are significantly worse. This creates gross inequity worldwide. Quality is a multi-‐dimensional concept and while complex to define, commonly agreed dimensions include: effectiveness, efficiency, equitability, timeliness, safety and patient-centeredness. My research focuses on the dimension of patient safety. Although many interventions to improve perioperative patient safety do exist, very few are widely implemented in LMICs. One of the greatest challenges therefore facing the global surgery community is how to take proven interventions and apply them successfully at scale in LMICs. The purpose of my research is to tackle this challenge head on, using the World Health Organisation (WHO) Surgical Safety Checklist (SSC) as an example. SSC usage rates in HICs are estimated at 88-89%, but less than 30% in LMICs. In all settings, the SSC has been repeatedly shown to reduce surgical mortality and morbidity. For clinicians, academics and policy-‐makers, the knowledge gap to be addressed is no longer, ‘does the SCC work?’ but, ‘how can [we] make the SSC work in our setting?’ And the relevant research questions are as follows: firstly, can the SSC be implemented successfully and sustainably at scale in LMICs; and secondly, is the effort required worth it? This thesis (incorporating five publications) aims to answer these questions by taking an implementation science-‐based approach to address the first question, and two different economic approaches to answer the second question. My overall goal in undertaking my research is to inform the knowledge gap in SSC implementation in LMICs, thereby ‘making surgery safer in LMICs in sub-Saharan Africa’. The over-arching methodological approach to my research is grounded within the discipline of implementation science. Implementation science research is a form of health policy and systems research that can be used to study and support the scale-up of evidenced quality improvement interventions and their subsequent integration into health systems at the national level. To achieve my research objectives I used three implementation science frameworks: the Expert Recommendation for Implementing Change, the Consolidated Framework for Implementation Research, and the Knowledge-to-Action Framework, and eight internationally recognised implementation outcomes. I employed a range of study designs and data analyses: systematic review and meta-analysis (Paper I); mixed-methods design, multivariate linear regression and thematic analysis (Papers II-IV); cost-effective analysis and cost-benefit analysis (Paper V). The systematic review and meta-‐analysis on SSC implementation in LMICs (Paper I) showed that most SSC implementations to date were single centre studies with poor reporting of implementation strategies. Estimates of clinical effectiveness showed SSC use was associated with a 23% reduction in mortality and a 44-‐56% reduction in complications. Nationwide SSC implementations in Madagascar, Benin and Cameroon that I undertook in collaboration with the non-governmental organisation Mercy Ships (Papers II-‐IV), showed SSC use increased significantly after a multi-faceted implementation strategy with high usage rates (74%, 86% and 54% respectively) sustained over time. Overall, most operating room staff reported positive personal and organisational benefits of SSC use, and the commonest barriers to use were lack of time and obstructive leadership. The economic evaluation (Paper V) showed that my model of nationwide SSC implementation was ‘very cost-effective’ by WHO standards and provides a return on investment of between $9 – 62 dollars for every $1 dollar spent. The research presented in this thesis shows that, to date, most SSC implementations in LMICs have been limited with few widespread initiatives, and generally poor reporting of the implementation process. The approach I have presented in the thesis for nationwide SSC scale up is feasible, has a positive and sustainable impact on personal and organisational practice, and is both cost-effective and of net-positive benefit to society. I conclude the thesis with reflections on my dual role as an implementor-evaluator and potential avenues for further integration of implementation methods in global health to achieve high quality perioperative care in sub-Saharan Africa.
Informing the knowledge gap of implementation of the World Health Organisation Surgical Safety Checklist in sub-Saharan Africa
White, M. (Author). 1 Apr 2021
Student thesis: Doctoral Thesis › Doctor of Philosophy