Understanding the knowledge of and potential challenges with implementation of Enhanced Recovery After Surgery in tertiary facilities in low-and middle-income countries for obstetric and gynecological surgery: A Qualitative Study

Understanding the knowledge of and potential challenges with implementation of Enhanced Recovery After Surgery in tertiary facilities in low-and middle-income countries for obstetric and gynecological surgery: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding the knowledge of and potential challenges with implementation of Enhanced Recovery After Surgery in tertiary facilities in low-and middle-income countries for obstetric and gynecological surgery: A Qualitative Study Anna Weimer, Adu Appiah-Kubi, Sarah Bell, Shannon Rush This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8019228/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Access to safe and affordable surgery in low- and middle-income countries has been identified as a growing need and driver of health disparity. Within the field of obstetrics and gynecology, surgical care is necessary for safe pregnancy care and curative gynecologic oncology care. Standardized perioperative care guidelines, such as Enhanced Recovery after Surgery (ERAS), have been identified as key components of improving quality surgical care globally. This study aimed to explore stakeholders' knowledge of, attitudes towards, and understood barriers and facilitators of ERAS implementation within a tertiary care hospital in Ho, Ghana. Methods Semi-structured interviews were conducted among clinical stakeholders caring for obstetrics and gynecology patients at Ho Teaching Hospital, a tertiary care teaching hospital in the Volta Region of Ghana. The interviews were transcribed verbatim, and data were analyzed by two researchers until consensus on coding structure was reached through an iterative process. Results Seven interviews were completed of nine clinical stakeholders including house officers (n = 1), residents (n = 4), and nurses (n = 3). A priori knowledge of ERAS was common among physicians, but lacking in nursing staff and degree of knowledge varied. Three themes emerged as both barriers and potential facilitators of implementation: physical resources, monetary resources, and human resources. Participants also universally expressed an acceptance of the efficacy and safety of ERAS, even when the protocols were a change from common practice. Conclusions ERAS was viewed as a safe, effective, and realistic strategy to improve surgical outcomes among obstetrics and gynecology patients. Although physical, monetary, and human resource limitations were repeatedly noted as barriers to realization, they were also identified as strengths of the system and modifiable problems. Targeted strategies that understand these limitations, address them systematically, and acknowledge the inherent strengths of the healthcare system in place will be needed to realize the benefits of ERAS in such settings. Enhanced Recovery After Surgery (ERAS) low- and middle-income countries (LMICs) global surgery obstetrics and gynecology women’s health Background In 2015, the Lancet Commission on Global Surgery identified global surgery as a pivotal component of a functional health care system and emphasized the global disparities in access to safe and affordable surgery in low- and middle-income countries (LMICs) and their impact on morbidity, mortality, and economic development. 1 They estimated that in 2015 there was an unmet need of 143 million procedures per year in LMICs with an expected associated cumulative loss of economic productivity of $ 12.3 billion USD from 2015 to 2030. The field of obstetrics and gynecology plays a key role in providing necessary surgical care, with an estimate of 15% of all pregnancies having complications that result in a need for surgical management. 2 Additionally, surgery is responsible for cancer cure in many gynecologic cancers, including early stage endometrial, ovarian, and cervical cancer. Not only is there an access gap to surgical care, but also a quality gap. One analysis found that, of the 4.2 million people that die within 30 days of surgery globally, half of those deaths occur in LMICs despite the disproportionately fewer cases that occur there. 3 There is also a paucity of data and metrics monitoring quality outcomes in LMICs. To address this quality gap, standardization of surgical and perioperative care has been suggested in the form of the National, Surgical, Obstetric and Anesthesia Plan (NSOAP), Surgical Safety Checklists (SSC), and Enhanced Recovery After Surgery (ERAS) program. 4 In high income countries, these initiatives have shown decreased length of stay, decreased complications, and reduction in readmission, but the uptake of these programs in LMICs is low and minimally studied. While there are specific perioperative guidelines that were adapted and contextualized from existing ERAS protocols for colorectal and gynecologic surgery to apply to LMICs, 5 they are not widely utilized. A number of groups have recommended identification and engagement with local stakeholders to tailor protocols to local settings and available resources as the key step in expanding utilization and adherence to ERAS. 6 – 8 This qualitative study aimed to explore the knowledge surrounding ERAS and to understand some of the barriers to ERAS implementation in surgical care for the obstetric and gynecologic surgical patient population in a single teaching institution in the Volta region of Ghana. Methods Design and Participants A semi-structured interview guide was designedfrom previously utilized questionnaires in similar studies in resource limited settings and reviewed by a local study team member (AAK) to ensure contextualized relevance and culture appropriateness (Table 1). Table 1: Semi-structured interview questions Semi-structure interview questions Have you heard of Enhanced Recovery After Surgery programs, also known as ERAS? If so, what is your understanding of the aims of these programs? Do you have any standardized practices that your facility uses for perioperative care? Can you provide specific examples? Are there any benefits to patient care and/or your practice that you can anticipate if there were standardized protocols for perioperative care? What might these be? At this point in the interview participants were provided with a list of the recommendations for ERAS implementation in gynecological surgery in low resources settings 5 Having read what ERAS is, what are your views of the ERAS program in relation to your clinical practice? In your clinic practice, what elements of ERAS are you or your colleagues currently using, if any? If so, how have these been implemented? Are they universally used or tailored to each patient? Is there a need for this intervention at your institution? Why or why not? Are there any elements of ERAS that you feel do not align with your patient population or hospital system? Do you have any concerns about any of the practices suggested by ERAS? If so, which practices and why? What potential downfalls of ERAS do you see, either in implementation or ensuring safe care for your patients? Judging from the current hospital policy management and basic resources, what do you think are the key factors that hinder the implementation of ERAS? During the perioperative period, which measures recommended by the ERAS guidelines have barriers and difficulties in implementation? What factors caused these barriers? What resources or support do you think would need to be obtained at your facility to be able to effectively implement ERAS? To what extent are new ideas embraced and used to make improvements in your hospital? Are there any reasons why providers may not be willing or able to adhere to ERAS guidelines if ERAS were to be implemented at your hospital? If so, what are they? What kind of supporting evidence or proof is needed about the effectiveness of ERAS to get staff on board? If you were to pick a specific practice of ERAS to implement in your facility, which practice would be the most beneficial to your patient and why? Which is the most feasible to implement and why? Do you have any other thoughts on the ERAS practices or possibility for implementation at your facility? Do you have any questions you would want answered about ERAS? Convenience sampling was used to identify potential clinical stakeholders providing care within gynecologic and obstetric departments, including obstetrics and gynecology attendings, anesthesiologists, nurses, pharmacists, and house officers. To meet inclusion criteria, participants had to be directly involved in surgical care of obstetric and gynecology patients and speak English. Once potential participants were identified, they were informed of the study purpose, risks, and confidentiality protections. Consent was obtained prior to the interview. Data Collection Procedures Interviews were conducted in person by an obstetrics and gynecology resident physician (A.W.). Interviews were conducted in English and were audio recorded and transcribed verbatim for analysis. Data Analysis Interviews were initially analyzed by two authors (A.W., S.B.). These research team members analyzed and coded the transcripts, separately before meeting to evaluate each code and agree on units of meaning for each transcript through an iterative process. Coding was not performed using a pre-determined list of codes; rather codes were formed inductively from the data itself. The codebook changed with each transcript until all transcripts were coded. The final codebook was created and applied to each transcript and codes were sorted into themes. Final themes and subthemes were reviewed and finalized by all authors to ensure consistency. Ethical Approval Formal ethical review and written approval were obtained by the International Review Board at both University of Pittsburgh and Ho Teaching Hospital. Results Seven interviews were completed with nine participants. One interview was not included in the analysis as the audio file was corrupted and unable to be transcribed. Four residents, one house officer, and three nurses were interviewed. The nurses were interviewed together as per their preference. Residents and house officers had a priori knowledge of ERAS, while the nurses interviewed were not aware of ERAS. While general knowledge among residents and house officers was universal, a comprehensive understanding of the standardized procedures was varied among participants. Resident 3: “Everyone is aware of what needs to be done at every particular point in time.” House Officer 1: “…to help patients recover well after surgery.” Participants recurrently spoke of three themes when discussing barriers to implementation of ERAS: physical resources, monetary resources, and human resources (Table 2). Notably there were no concerns from participants about the efficacy of ERAS nor about patient safety or well-being with implementation, even when the protocols were a change from common practice. Table 2: Emergent themes of qualitative interviews on the barriers and facilitators for ERAS implementation Barriers Facilitator Physical Resources -Functionality of available resources -Consistent access to resources -Resources already exist Monetary Resources -Concern about cost falling on patients -Inadequate resources to fund changes -Power to overcome with persistence Person resources -Inadequate personnel to enact changes -Need to change mindsets -Power of clinical leaders, e.g. attending physicians -Importance of engagement with direct care providers Physical resources Participants highlighted that ERAS was feasible in their environment largely because they already possessed the resources to complete it as they were loosely following many of the protocols already. Resident 1: "And I think the reason why I think these are possible in our environment is because we have the necessary materials necessary to implement them and they are easily available, and I think that [is] why they are easy." Participants recognized that not every resource was always available, consistently available, or fully functional. House officer 1 : “...also the equipment and the operative tools we don’t have all of them here so that is the one challenging thing." Resident 1: “occasions where we may not have any of these medications available, whether enoxaparin or denoxaparin, and when those occur the patients end up not having that.” Resident 4: “And the normothermia, temperature control, we can warm them but we can’t necessarily; we are [not] getting them to a certain degree because the technology we have does not necessarily tell them what temperature they are at." Resident 1: “We use to have one [bear hugger] up there and then it got old so I don’t know if it has been repaired, but it’s one.” Monetary resources Unlike other themes, stakeholders identified monetary resources as a pure barrier rather than a facilitator. Specifically, they noted the monetary burden of any healthcare service on patients. Resident 3: “...everything is by payment which makes it challenging for clients to get some medications and services." House officer 1: “"Some of the clients have no social economic status, so because of that some of them are not able to get things done properly." Resident 1: “Thromboembolism stockings are quite expensive so for those that can provide, fine we let the get it and then they use it post-surgery, but those that can’t provide we can’t force them to buy so...” Resident 2: “For over here, I think pneumatic compressors, we can’t afford and things that like that we can’t afford. Money issues.” Despite monetary concerns about implementation, stakeholders were not deterministic and identified that this barrier could be overcome if the drive to do so was there. Resident 2: "Africa we are poor. So it’s all about the money, money, money. It gets mismanaged. So they will tell you we don’t have the resources. But I think that most of the things here are not too farfetched. I think that the willingness to execute it is the key. We have to. I don’t think these things are too big to be done." Human resources The staff’s ability to deliver care was recurrently identified as a barrier to implementation. House officer 1: "Inadequate personnel so um every patient ideal is supposed to have one nurse or a doctor to take care of them, but oh we don’t have it like that over here so that is one of the challenges that we have yeah.” Nurses 1, 2, and 3: “Sometimes we come on duty and the staff strength is very low where we have very few staff to implement some of these things so staff strength is key.” Stakeholders consistently identified the potential in leadership to facilitate ERAS implementation, both as champions of the effort at the top of the system and on the ground as enactors of the protocols. Resident 2: “So once the bosses* themselves acknowledge the essence of ERAS, what they need to do is dissemination of information, educating their people, yes so once at management level, pushing it and then institutionalizing it in the unit, so basically on them. Once the bosses are forth coming with it. [It will happen]." Resident 1: “...that is our bosses are the champion of the ERAS cause” *Within this healthcare system, the attending physicians were referred to as the “bosses.” Resident 4: “Because most of these things are implemented by the nurses so you have to involve them." Discussion There have been several studies in discrete populations assessing provider identified barriers and facilitators to ERAS implementation, but to our knowledge this is the first that focused on ERAS implementation in Ghana and, specifically, within a gynecologic patient population. This study reveals some of the contextualized concerns with implementation within the Ghanaian health care system, including the disproportionate burden of ERAS implementation on patients given predominantly out-of-pocket healthcare financing and the inconsistent availability and functionality of the physical resources needed for standardization of perioperative care under ERAS. Among literature focusing on perioperative care in LMICs, cost and availability of resources are repeatedly cited as major barriers to standardized implementation. 9 Our participants also highlighted this concern and noted issues with resource cost, supply chain availability (i.e., medication shortages), and resource functionality (i.e., malfunctioning bear hugger devices). Despite these challenges, participants noted that these issues were consistent with their larger system and should not be a deterrent to ERAS implementation as many of the required resources were available. Furthermore, they noted they were accustomed to using alternatives when needed such as using local private medication suppliers for medications when the hospital stock was out. This points to a need for contextualized adaptive solutions to focus on maximizing the available ERAS-related resources and targeted efforts to troubleshoot resource scarcity as it inevitably arises. Patient related cost has long been noted as a barrier to surgical care access in LMICs, but there is less documented about the implications for perioperative care management and the impact on attempts to standardize care when the cost of that standardization is borne by the patient. 10 Participants in this study repeatedly noted that while their healthcare system would likely support ERAS implementation, it was the patient that would have to pay for all elements – including medications, intravenous fluid, nutritional supplementation, perioperative food and drink, and use of any non-reusable medical device. Therefore, implementation would be severely blunted by individual patient’s abilities to afford the associated cost. As noted by participants in this study, some of the ERAS interventions are cost independent and could be implemented without additional cost burden to patients. This study highlights the importance of considering patient cost when implementing ERAS protocols in LMICs. Despite financial challenges, participants noted the power of people within their system to support and realize ERAS. As was identified in a similar study in Pakistan, our participants emphasized the power of care teams to bolster ERAS utilization from both a top-down and bottom-up standpoint. 11 Participants identified the “bosses,” the attending physicians within their system, as key stakeholders to ensuring ERAS implementation. In the hierarchical medical system where the attending physicians have final ownership over medical decisions and serve as the face of the perioperative team, these providers have the ultimate power to initiate and enforce change. Physician acceptance or lack thereof has recurrently been cited a strong facilitator or barrier respectively to ERAS implementation. 12-13 As participants noted, if the attending physicians align their practice with ERAS and support its utilization, the drive behind the effort then exists and they have the power to enforce change. Participants acknowledge that, while the attending physicians supply the drive, the nursing staff supply the action. The pivotal role that nursing staff play in the hands-on delivery of ERAS-based care and patient education was clearly stated by several participants and the need for adequate nursing personnel, training, and education was noted. Nurses are key drivers of ERAS implementation and their role in optimizing perioperative care through ERAS-based nursing is well documented. 14-16 Proportionately, nursing staff spend the most time with patients during the perioperative period and have the unique opportunity to facilitate the hands-on delivery of ERAS-based care so implementation hinges on collaboration and nursing buy-in. While this study provides a contextualized understanding of potential barriers and facilitators of ERAS supplied by those who have a deep understanding of their own health care system, it has several limitations. First is the limited scope of the findings to a single site in one country. Additionally, as the interviewer was from a high-income country, courtesy bias may have led respondents to speak more favorably towards ERAS and its implementation than they may have otherwise. Furthermore, as the study utilized convenience sampling, the full spectrum of stakeholders was not interviewed and would have included pharmacists, anesthesiologists, and attending physicians. Conclusion In conclusion, although potentially limited by availability of material and personnel resources and high patient-based cost, ERAS is understood to be a beneficial tool to improve perioperative patient outcomes and felt to be largely feasible within this Ghanaian hospital provided appropriate support and dedication. Realizing the benefits of ERAS will take a targeted approach focusing on strategies to minimize patient cost burden, development of robust plans to systematically adapt when resources are not available, and support for a team-driven approach to champion, educate, and enact ERAS. Abbreviations ERAS Enhanced Recovery After Surgery LMICs low-and middle-income countries NSOAP National, Surgical, Obstetric and Anesthesia Plan SSC Surgical Safety Checklists AAK Adu Appiah-Kubi AW Anna Weimer SB Sarah Bell Declarations Ethics approval and consent to participate: All methods were carried out in accordance with relevant guidelines and regulations including the compliance with the Declaration of Helsinki and were approved by both the local and outside institution IRB. Formal ethical review and written approval were obtained by the International Review Board at both University of Pittsburgh (Study 23070044) and Ho Teaching Hospital (ID HTH-REC (37) FC_2023). All participants provided written and verbal consent to participate and to recording prior to interview completion. Consent for publication: Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests All authors confirm that they have no competing interests as it relates to this work. Funding No funding was obtained to complete this project. Authors’ contributions All authors contributed substantively to this work. AW contributed to study conception and design, data collection and analysis, and manuscript drafting. AAK also contributed to study conception and design, oversaw data collections, and participated in manuscript drafting. SB contributed to study conception and design, data analysis and manuscript drafting. SR oversaw study conception and design and participated in data and manuscript review. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 02 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviewers invited by journal 01 Dec, 2025 Editor assigned by journal 26 Nov, 2025 Editor invited by journal 07 Nov, 2025 Submission checks completed at journal 05 Nov, 2025 First submitted to journal 05 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8019228","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":554058391,"identity":"d8631ea2-f77a-4b28-b666-18f1c66eb2b3","order_by":0,"name":"Anna Weimer","email":"","orcid":"","institution":"University of Pittsburgh Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Weimer","suffix":""},{"id":554058392,"identity":"3233ec46-7cd0-4fe4-8c04-80ac14577472","order_by":1,"name":"Adu 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16:40:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":628881,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8019228/v1/16b976d0-26e3-4f1f-a6c6-e8dfa0e1a725.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding the knowledge of and potential challenges with implementation of Enhanced Recovery After Surgery in tertiary facilities in low-and middle-income countries for obstetric and gynecological surgery: A Qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eIn 2015, the Lancet Commission on Global Surgery identified global surgery as a pivotal component of a functional health care system and emphasized the global disparities in access to safe and affordable surgery in low- and middle-income countries (LMICs) and their impact on morbidity, mortality, and economic development.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e They estimated that in 2015 there was an unmet need of 143\u0026nbsp;million procedures per year in LMICs with an expected associated cumulative loss of economic productivity of \u003cspan\u003e$\u003c/span\u003e12.3\u0026nbsp;billion USD from 2015 to 2030. The field of obstetrics and gynecology plays a key role in providing necessary surgical care, with an estimate of 15% of all pregnancies having complications that result in a need for surgical management.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Additionally, surgery is responsible for cancer cure in many gynecologic cancers, including early stage endometrial, ovarian, and cervical cancer.\u003c/p\u003e\u003cp\u003eNot only is there an access gap to surgical care, but also a quality gap. One analysis found that, of the 4.2\u0026nbsp;million people that die within 30 days of surgery globally, half of those deaths occur in LMICs despite the disproportionately fewer cases that occur there.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e There is also a paucity of data and metrics monitoring quality outcomes in LMICs. To address this quality gap, standardization of surgical and perioperative care has been suggested in the form of the National, Surgical, Obstetric and Anesthesia Plan (NSOAP), Surgical Safety Checklists (SSC), and Enhanced Recovery After Surgery (ERAS) program.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In high income countries, these initiatives have shown decreased length of stay, decreased complications, and reduction in readmission, but the uptake of these programs in LMICs is low and minimally studied. While there are specific perioperative guidelines that were adapted and contextualized from existing ERAS protocols for colorectal and gynecologic surgery to apply to LMICs,\u003csup\u003e5\u003c/sup\u003e they are not widely utilized.\u003c/p\u003e\u003cp\u003eA number of groups have recommended identification and engagement with local stakeholders to tailor protocols to local settings and available resources as the key step in expanding utilization and adherence to ERAS.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e This qualitative study aimed to explore the knowledge surrounding ERAS and to understand some of the barriers to ERAS implementation in surgical care for the obstetric and gynecologic surgical patient population in a single teaching institution in the Volta region of Ghana.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDesign and Participants\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA semi-structured interview guide was designedfrom previously utilized questionnaires in similar studies in resource limited settings and reviewed by a local study team member (AAK) to ensure contextualized relevance and culture appropriateness (Table 1).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 1: Semi-structured interview questions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 618px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Semi-structure interview questions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eHave you heard of Enhanced Recovery After Surgery programs, also known as ERAS? \u0026nbsp;If so, what is your understanding of the aims of these programs?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eDo you have any standardized practices that your facility uses for perioperative care? \u0026nbsp;Can you provide specific examples?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eAre there any benefits to patient care and/or your practice that you can anticipate if there were standardized protocols for perioperative care? \u0026nbsp;What might these be?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101.937%;\"\u003e\n \u003cp\u003e\u003cem\u003eAt this point in the interview participants were provided with a list of the recommendations for ERAS implementation in gynecological surgery in low resources settings\u003c/em\u003e\u003cem\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eHaving read what ERAS is, what are your views of the ERAS program in relation to your clinical practice?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eIn your clinic practice, what elements of ERAS are you or your colleagues currently using, if any? \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eIf so, how have these been implemented? \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAre they universally used or tailored to each patient?\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eIs there a need for this intervention at your institution? \u0026nbsp; \u0026nbsp; Why or why not?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eAre there any elements of ERAS that you feel do not align with your patient population or hospital system?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDo you have any concerns about any of the practices suggested by ERAS? \u0026nbsp;If so, which practices and why?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eWhat potential downfalls of ERAS do you see, either in implementation or ensuring safe care for your patients?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eJudging from the current hospital policy management and basic resources, what do you think are the key factors that hinder the implementation of ERAS?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eDuring the perioperative period, which measures recommended by the ERAS guidelines have barriers and difficulties in implementation? What factors caused these barriers?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eWhat resources or support do you think would need to be obtained at your facility to be able to effectively implement ERAS?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eTo what extent are new ideas embraced and used to make improvements in your hospital?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eAre there any reasons why providers may not be willing or able to adhere to ERAS guidelines if ERAS were to be implemented at your hospital? \u0026nbsp;If so, what are they?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eWhat kind of supporting evidence or proof is needed about the effectiveness of ERAS to get staff on board?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eIf you were to pick a specific practice of ERAS to implement in your facility, which practice would be the most beneficial to your patient and why? \u0026nbsp;Which is the most feasible to implement and why?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99.7578%;\"\u003e\n \u003cp\u003eDo you have any other thoughts on the ERAS practices or possibility for implementation at your facility? \u0026nbsp;Do you have any questions you would want answered about ERAS?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eConvenience sampling was used to identify potential clinical stakeholders providing care within gynecologic and obstetric departments, including obstetrics and gynecology attendings, anesthesiologists, nurses, pharmacists, and house officers. To meet inclusion criteria, participants had to be directly involved in surgical care of obstetric and gynecology patients and speak English. Once potential participants were identified, they were informed of the study purpose, risks, and confidentiality protections. Consent was obtained prior to the interview. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Collection Procedures\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterviews were conducted in person by an obstetrics and gynecology resident physician (A.W.). \u0026nbsp;Interviews were conducted in English and were audio recorded and transcribed verbatim for analysis. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterviews were initially analyzed by two authors (A.W., S.B.). These research team members analyzed and coded the transcripts, separately before meeting to evaluate each code and agree on units of meaning for each transcript through an iterative process. Coding was not performed using a pre-determined list of codes; rather codes were formed inductively from the data itself. The codebook changed with each transcript until all transcripts were coded. The final codebook was created and applied to each transcript and codes were sorted into themes. Final themes and subthemes were reviewed and finalized by all authors to ensure consistency. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical Approval\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFormal ethical review and written approval were obtained by the International Review Board at both University of Pittsburgh and Ho Teaching Hospital.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSeven interviews were completed with nine participants. One interview was not included in the analysis as the audio file was corrupted and unable to be transcribed. Four residents, one house officer, and three nurses were interviewed. The nurses were interviewed together as per their preference. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResidents and house officers had a priori knowledge of ERAS, while the nurses interviewed were not aware of ERAS. While general knowledge among residents and house officers was universal, a comprehensive understanding of the standardized procedures was varied among participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 3: \u003cem\u003e\u0026ldquo;Everyone is aware of what needs to be done at every particular point in time.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHouse Officer 1:\u003cem\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;to help patients recover well after surgery.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants recurrently spoke of three themes when discussing barriers to implementation of ERAS: physical resources, monetary resources, and human resources (Table 2). Notably there were no concerns from participants about the efficacy of ERAS nor about patient safety or well-being with implementation, even when the protocols were a change from common practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Emergent themes of qualitative interviews on the barriers and facilitators for ERAS implementation \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitator\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical Resources\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003e-Functionality of available resources\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-Consistent access to resources\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e-Resources already exist \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonetary Resources\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003e-Concern about cost falling on patients\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-Inadequate resources to fund changes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e-Power to overcome with persistence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerson resources\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003e-Inadequate personnel to enact changes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-Need to change mindsets\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e-Power of clinical leaders, e.g. attending physicians\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-Importance of engagement with direct care providers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical resources\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants highlighted that ERAS was feasible in their environment largely because they already possessed the resources to complete it as they were loosely following many of the protocols already.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 1:\u003cem\u003e\u0026nbsp;\u0026quot;And I think the reason why I think these are possible in our environment is because we have the necessary materials necessary to implement them and they are easily available, and I think that [is] why they are easy.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants recognized that not every resource was always available, consistently available, or fully functional.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHouse officer 1\u003cem\u003e: \u0026ldquo;...also the equipment and the operative tools we don\u0026rsquo;t have all of them here so that is the one challenging thing.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 1: \u003cem\u003e\u0026ldquo;occasions where we may not have any of these medications available, whether enoxaparin or denoxaparin, and when those occur the patients end up not having that.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 4: \u003cem\u003e\u0026ldquo;And the normothermia, temperature control, we can warm them but we can\u0026rsquo;t necessarily; we are [not] getting them to a certain degree because the technology we have does not necessarily tell them what temperature they are at.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 1:\u003cem\u003e\u0026nbsp;\u0026ldquo;We use to have one [bear hugger] up there and then it got old so I don\u0026rsquo;t know if it has been repaired, but it\u0026rsquo;s one.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMonetary resources\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnlike other themes, stakeholders identified monetary resources as a pure barrier rather than a facilitator. Specifically, they noted the monetary burden of any healthcare service on patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 3:\u003cem\u003e\u0026nbsp;\u0026ldquo;...everything is by payment which makes it challenging for clients to get some medications and services.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHouse officer 1:\u003cem\u003e\u0026nbsp;\u0026ldquo;\u0026quot;Some of the clients have no social economic status, so because of that some of them are not able to get things done properly.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 1:\u003cem\u003e\u0026nbsp;\u0026ldquo;Thromboembolism stockings are quite expensive so for those that can provide, fine we let the get it and then they use it post-surgery, but those that can\u0026rsquo;t provide we can\u0026rsquo;t force them to buy so...\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 2:\u003cem\u003e\u0026nbsp;\u0026ldquo;For over here, I think pneumatic compressors, we can\u0026rsquo;t afford and things that like that we can\u0026rsquo;t afford. \u0026nbsp;Money issues.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite monetary concerns about implementation, stakeholders were not deterministic and identified that this barrier could be overcome if the drive to do so was there.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 2:\u003cem\u003e\u0026nbsp;\u0026quot;Africa we are poor. So it\u0026rsquo;s all about the money, money, money. It gets mismanaged. So they will tell you we don\u0026rsquo;t have the resources. But I think that most of the things here are not too farfetched. I think that the willingness to execute it is the key. We have to. I don\u0026rsquo;t think these things are too big to be done.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman resources\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe staff\u0026rsquo;s ability to deliver care was recurrently identified as a barrier to implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHouse officer 1:\u003cem\u003e\u0026nbsp;\u0026quot;Inadequate personnel so um every patient ideal is supposed to have one nurse or a doctor to take care of them, but oh we don\u0026rsquo;t have it like that over here so that is one of the challenges that we have yeah.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNurses 1, 2, and 3:\u003cem\u003e\u0026nbsp;\u0026ldquo;Sometimes we come on duty and the staff strength is very low where we have very few staff to implement some of these things so staff strength is key.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStakeholders consistently identified the potential in leadership to facilitate ERAS implementation, both as champions of the effort at the top of the system and on the ground as enactors of the protocols.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 2:\u003cem\u003e\u0026nbsp;\u0026ldquo;So once the bosses* themselves acknowledge the essence of ERAS, what they need to do is dissemination of information, educating their people, yes so once at management level, pushing it and then institutionalizing it in the unit, so basically on them. Once the bosses are forth coming with it. [It will happen].\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 1:\u003cem\u003e\u0026nbsp;\u0026ldquo;...that is our bosses are the champion of the ERAS cause\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Within this healthcare system, the attending physicians were referred to as the \u0026ldquo;bosses.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResident 4:\u003cem\u003e\u0026nbsp;\u0026ldquo;Because most of these things are implemented by the nurses so you have to involve them.\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere have been several studies in discrete populations assessing provider identified barriers and facilitators to ERAS implementation, but to our knowledge this is the first that focused on ERAS implementation in Ghana and, specifically, within a gynecologic patient population. \u0026nbsp; This study reveals some of the contextualized concerns with implementation within the Ghanaian health care system, including the disproportionate burden of ERAS implementation on patients given predominantly out-of-pocket healthcare financing and the inconsistent availability and functionality of the physical resources needed for standardization of perioperative care under ERAS. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong literature focusing on perioperative care in LMICs, cost and availability of resources are repeatedly cited as major barriers to standardized implementation.\u003csup\u003e9\u003c/sup\u003e Our participants also highlighted this concern and noted issues with resource cost, supply chain availability (i.e., medication shortages), and resource functionality (i.e., malfunctioning bear hugger devices). \u0026nbsp;Despite these challenges, participants noted that these issues were consistent with their larger system and should not be a deterrent to ERAS implementation as many of the required resources were available. Furthermore, they noted they were accustomed to using alternatives when needed such as using local private medication suppliers for medications when the hospital stock was out. \u0026nbsp; This points to a need for contextualized adaptive solutions to focus on maximizing the available ERAS-related resources and targeted efforts to troubleshoot resource scarcity as it inevitably arises.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatient related cost has long been noted as a barrier to surgical care access in LMICs, but there is less documented about the implications for perioperative care management and the impact on attempts to standardize care when the cost of that standardization is borne by the patient.\u003csup\u003e10\u0026nbsp;\u003c/sup\u003eParticipants in this study repeatedly noted that while their healthcare system would likely support ERAS implementation, it was the patient that would have to pay for all elements – including medications, intravenous fluid, nutritional supplementation, perioperative food and drink, and use of any non-reusable medical device. Therefore, implementation would be severely blunted by individual patient’s abilities to afford the associated cost. As noted by participants in this study, some of the ERAS interventions are cost independent and could be implemented without additional cost burden to patients. This study highlights the importance of considering patient cost when implementing ERAS protocols in LMICs.\u003c/p\u003e\n\u003cp\u003eDespite financial challenges, participants noted the power of people within their system to support and realize ERAS. As was identified in a similar study in Pakistan, our participants emphasized the power of care teams to bolster ERAS utilization from both a top-down and bottom-up standpoint.\u003csup\u003e11\u003c/sup\u003e Participants identified the “bosses,” the attending physicians within their system, as key stakeholders to ensuring ERAS implementation. In the hierarchical medical system where the attending physicians have final ownership over medical decisions and serve as the face of the perioperative team, these providers have the ultimate power to initiate and enforce change. Physician acceptance or lack thereof has recurrently been cited a strong facilitator or barrier respectively to ERAS implementation.\u003csup\u003e12-13\u003c/sup\u003e As participants noted, if the attending physicians align their practice with ERAS and support its utilization, the drive behind the effort then exists and they have the power to enforce change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants acknowledge that, while the attending physicians supply the drive, the nursing staff supply the action. The pivotal role that nursing staff play in the hands-on delivery of ERAS-based care and patient education was clearly stated by several participants and the need for adequate nursing personnel, training, and education was noted. \u0026nbsp;Nurses are key drivers of ERAS implementation and their role in optimizing perioperative care through ERAS-based nursing is well documented.\u003csup\u003e14-16\u003c/sup\u003e Proportionately, nursing staff spend the most time with patients during the perioperative period and have the unique opportunity to facilitate the hands-on delivery of ERAS-based care so implementation hinges on collaboration and nursing buy-in.\u003c/p\u003e\n\u003cp\u003eWhile this study provides a contextualized understanding of potential barriers and facilitators of ERAS supplied by those who have a deep understanding of their own health care system, it has several limitations. First is the limited scope of the findings to a single site in one country. Additionally, as the interviewer was from a high-income country, courtesy bias may have led respondents to speak more favorably towards ERAS and its implementation than they may have otherwise. Furthermore, as the study utilized convenience sampling, the full spectrum of stakeholders was not interviewed and would have included pharmacists, anesthesiologists, and attending physicians. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, although potentially limited by availability of material and personnel resources and high patient-based cost, ERAS is understood to be a beneficial tool to improve perioperative patient outcomes and felt to be largely feasible within this Ghanaian hospital provided appropriate support and dedication. Realizing the benefits of ERAS will take a targeted approach focusing on strategies to minimize patient cost burden, development of robust plans to systematically adapt when resources are not available, and support for a team-driven approach to champion, educate, and enact ERAS.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eERAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnhanced Recovery After Surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003elow-and middle-income countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSOAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational, Surgical, Obstetric and Anesthesia Plan\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSurgical Safety Checklists\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAAK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdu Appiah-Kubi\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnna Weimer\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSarah Bell\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations including the compliance with the Declaration of Helsinki and were approved by both the local and outside institution IRB.\u0026nbsp;\u0026nbsp;Formal ethical review and written approval were obtained by the International Review Board at both University of Pittsburgh (Study 23070044) and Ho Teaching Hospital (ID HTH-REC (37) FC_2023). \u0026nbsp;All participants provided written and verbal consent to participate and to recording prior to interview completion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors confirm that they have no competing interests as it relates to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained to complete this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed substantively to this work. \u0026nbsp; AW contributed to study conception and design, data collection and analysis, and manuscript drafting. \u0026nbsp;AAK also contributed to study conception and design, oversaw data collections, and participated in manuscript drafting. \u0026nbsp;SB contributed to study conception and design, data analysis and manuscript drafting. \u0026nbsp;SR oversaw study conception and design and participated in data and manuscript review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMeara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, M\u0026eacute;risier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. 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Construction and application of enhanced recovery after surgery-optimized management system with nurse-led multidisciplinary cooperation. Nurs Open. 2023;10(7):4526\u0026ndash;35. Epub 2023 Feb 28. PMID: 36855236; PMCID: PMC10277420.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enhanced Recovery After Surgery (ERAS), low- and middle-income countries (LMICs), global surgery, obstetrics and gynecology, women’s health","lastPublishedDoi":"10.21203/rs.3.rs-8019228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8019228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAccess to safe and affordable surgery in low- and middle-income countries has been identified as a growing need and driver of health disparity. Within the field of obstetrics and gynecology, surgical care is necessary for safe pregnancy care and curative gynecologic oncology care. Standardized perioperative care guidelines, such as Enhanced Recovery after Surgery (ERAS), have been identified as key components of improving quality surgical care globally. This study aimed to explore stakeholders' knowledge of, attitudes towards, and understood barriers and facilitators of ERAS implementation within a tertiary care hospital in Ho, Ghana.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e Semi-structured interviews were conducted among clinical stakeholders caring for obstetrics and gynecology patients at Ho Teaching Hospital, a tertiary care teaching hospital in the Volta Region of Ghana. The interviews were transcribed verbatim, and data were analyzed by two researchers until consensus on coding structure was reached through an iterative process.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSeven interviews were completed of nine clinical stakeholders including house officers (n\u0026thinsp;=\u0026thinsp;1), residents (n\u0026thinsp;=\u0026thinsp;4), and nurses (n\u0026thinsp;=\u0026thinsp;3). A priori knowledge of ERAS was common among physicians, but lacking in nursing staff and degree of knowledge varied. Three themes emerged as both barriers and potential facilitators of implementation: physical resources, monetary resources, and human resources. Participants also universally expressed an acceptance of the efficacy and safety of ERAS, even when the protocols were a change from common practice.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eERAS was viewed as a safe, effective, and realistic strategy to improve surgical outcomes among obstetrics and gynecology patients. Although physical, monetary, and human resource limitations were repeatedly noted as barriers to realization, they were also identified as strengths of the system and modifiable problems. Targeted strategies that understand these limitations, address them systematically, and acknowledge the inherent strengths of the healthcare system in place will be needed to realize the benefits of ERAS in such settings.\u003c/p\u003e","manuscriptTitle":"Understanding the knowledge of and potential challenges with implementation of Enhanced Recovery After Surgery in tertiary facilities in low-and middle-income countries for obstetric and gynecological surgery: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 16:37:34","doi":"10.21203/rs.3.rs-8019228/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-02T10:18:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306468015354836321637927386977820261334","date":"2025-12-01T22:29:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-01T18:28:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-26T11:12:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-07T12:24:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-05T20:36:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-11-05T20:34:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8dd58715-5e63-43d6-b6ec-52405e363245","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-03T16:37:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-03 16:37:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8019228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8019228","identity":"rs-8019228","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}