Reynolds Christopher W, Cassell Ayun, Mabanza Tresor, Rooney Deborah M, Kollie Ronald, O'Reggio Rachel, Moore-Wilson Yarvoh, Ketia Aaron, Lemfuka Dieudonné A, Jeffcoach David, Kim Grace J
Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
John F. Kennedy Medical Center, 22nd St. & Tubman Blvd. Sinkor, Monrovia, Liberia.
Surg Endosc. 2025 Jan;39(1):582-593. doi: 10.1007/s00464-024-11340-6. Epub 2024 Oct 25.
Significant disparities exist in laparoscopic training opportunities for surgeons in low- and middle-income countries (LMICs). ALL-SAFE is an innovative, low-cost training system for LMIC surgeons' laparoscopic development. However, strategies to implement and scale ALL-SAFE are unstudied. We aimed to assess the impact of implementation science strategies on ALL-SAFE uptake in Liberia, a novel and low-resource context.
This study used implementation science approaches to evaluate ALL-SAFE uptake in three Liberian hospitals: John F. Kennedy Medical Center, Phebe, and ELWA. Five validated implementation strategies of program orientation, local champions, network weaving, feedback mechanisms, and practical supervision were piloted. All five strategies were implemented at two hospitals, while four strategies, excluding clinician supervision, were implemented at the final site as a pseudo-control, to evaluate the impact of resource-intensive supervision. Participants included surgical consultants, residents, and medical students. Engagement was assessed with mixed methods including participant number, practice hours, module completion rates, and strategy feasibility through end-user interviews.
Across three hospitals, 33 participants used ALL-SAFE for 87.8 total training hours (5,268 min). Participant numbers varied across sites (N = 20, 80%; N = 7, 88%; N = 6, 86%), as did practice times (Total = 3,060 min, Median time/Participant = 103 min; Total = 1,434 min, Median time/Participant = 126 min; Total = 774 min, Median time/Participant = 100 min). Sites with practical supervision demonstrated higher engagement than those without (P = 0.042). Interviews (n = 8) revealed positive perceptions toward program orientation, practical supervision, and network weaving. Participants recommended thirteen additional strategies for sustainability including translating ALL-SAFE skills to patient care.
Our study is one of the first to evaluate implementation science strategies for laparoscopic training in sub-Saharan Africa. The implementation bundles of five validated strategies were considered feasible by Liberian surgeons in both urban and rural hospitals. Mixed methods suggested a positive association between engagement and the resource-intensive practical supervision strategy. Future studies should focus on quantifying individual strategy contributions with rigorous implementation designs and assessing sustainability strategies.
低收入和中等收入国家（LMICs）外科医生的腹腔镜培训机会存在显著差异。ALL-SAFE是一种用于LMICs外科医生腹腔镜技术发展的创新型低成本培训系统。然而，实施和推广ALL-SAFE的策略尚未得到研究。我们旨在评估实施科学策略对利比里亚（一个新颖且资源匮乏的环境）采用ALL-SAFE的影响。
本研究采用实施科学方法，在利比里亚的三家医院评估ALL-SAFE的采用情况：约翰·F·肯尼迪医疗中心、菲比医院和ELWA医院。试点了项目导向、当地倡导者、网络编织、反馈机制和实践监督这五种经过验证的实施策略。所有五种策略在两家医院实施，而在最后一家医院作为伪对照实施了四种策略（不包括临床医生监督），以评估资源密集型监督的影响。参与者包括外科顾问、住院医生和医学生。通过混合方法评估参与情况，包括参与者数量、练习时间、模块完成率以及通过终端用户访谈评估策略的可行性。
在三家医院中，33名参与者使用ALL-SAFE进行了总计87.8小时（5268分钟）的培训。各地点的参与者数量有所不同（分别为N = 20，80%；N = 7，88%；N = 6，86%），练习时间也不同（总计分别为3060分钟，参与者平均时间为103分钟；总计1434分钟，参与者平均时间为126分钟；总计774分钟，参与者平均时间为100分钟）。有实践监督的地点比没有实践监督的地点参与度更高（P = 0.042）。访谈（n = 8）显示对项目导向、实践监督和网络编织有积极看法。参与者推荐了另外13种可持续性策略，包括将ALL-SAFE技能应用于患者护理。
我们的研究是首批评估撒哈拉以南非洲腹腔镜培训实施科学策略的研究之一。利比里亚城乡医院的外科医生认为这五种经过验证的策略组合是可行的。混合方法表明参与度与资源密集型实践监督策略之间存在正相关。未来的研究应侧重于通过严格的实施设计量化各个策略的贡献，并评估可持续性策略。
