Article Text
Abstract
Objective While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children’s surgery is addressed is not well-known. This study aims to assess the inclusion of children’s surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children’s surgical care in future policies.
Design We performed two qualitative content analyses to assess the inclusion of children’s surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children’s Surgery’s Optimal Resources for Children’s Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia.
Results Our framework for the inclusion of children’s surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed ‘human resources and training’ and ‘infrastructure’, four addressed ‘service delivery’, three addressed ‘governance and financing’, two included ‘research, evaluation and quality improvement’, and one NSOAP addressed ‘equipment and supplies’ and ‘advocacy and awareness’.
Conclusions Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children’s surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children’s surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.
- SURGERY
- Health policy
- Paediatric surgery
- QUALITATIVE RESEARCH
Data availability statement
Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplemental information. All data relevant to the study are publicly available and are included in the article or uploaded as supplemental material.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
To our knowledge, this is the first study to analyse the inclusion of children’s surgical care in National Surgical, Obstetric and Anaesthesia Plans (NSOAPs).
We developed a policy analysis framework based on the Global Initiative for Children’s Surgery’s Optimal Resources for Children’s Surgery.
This study outlines practice examples of countries and provides recommendations to scale up surgical care for children.
Limitations include the application of a standardised analytical framework to NSOAPs that is specific to the country’s needs and existing healthcare structure, and likely under-reporting on strategies and existing infrastructure for children’s surgical care.
Introduction
Five billion people globally—including 1.7 billion children—lack access to safe, affordable, and timely surgical and anaesthesia care, with a disproportionate need in low/middle-income countries (LMICs).1 2 Children under 15 years represent one-quarter of the world’s population, and close to 90% of children globally live in LMICs.2 To address children’s surgical needs, children’s surgery should play an important role in the scale-up of surgical healthcare systems as an estimated 85% of children will require some form of surgery by the time they are 15 years.2 3 Furthermore, as childhood deaths from infectious diseases and malnutrition decreased in the last decades,4 5 congenital anomalies are now the fifth leading cause of death in children under the age of 5 years, constituting 9% of the global surgical burden of disease.6 Additionally, surgery is the only treatment option for many childhood diseases, including congenital anomalies, cancer, injuries and other emergencies in regions with low resources.7
Expanding surgical care has long been neglected, as it was considered a complex and expensive intervention with limited public health benefits compared with treating and preventing communicable diseases.8 In 2015, the Lancet Commission on Global Surgery (LCoGS)1 and Disease Control Priorities Third Edition9 highlighted the critical need to improve global surgical care. This was followed by the World Health Assembly resolution 68.15,10 which prioritised the strengthening of surgical healthcare systems as a component of universal health coverage. Recognising the unique needs of children, the Global Initiative for Children’s Surgery (GICS) was established in 2016 to combine the experience and capabilities of children’s surgery providers in LMICs with the resources and expertise of high-income country partners.4 To provide guidelines for essential surgical care for children in LMICs, working groups under LMIC leadership were convened with representation from all aspects of children’s surgical care including surgery and surgical subspecialties, anaesthesia and allied health professionals from 44 different countries. Four independent working groups were formed to provide guidelines and recommendations along the domains of (1) ‘research, data and quality improvement’, (2) ‘financing, policy and advocacy’, (3) ‘training, human resources and education’, and (4) ‘infrastructure and standards’. This unique, multidisciplinary strategy resulted in the publication of the Optimal Resources for Children’s Surgery (OReCS) document, which outlines guidelines for different levels of care and the resources required.5 7 OReCS provides a framework against which gaps in existing children’s surgical care can be identified, and efforts made to integrate this essential component of surgical services into existing and ongoing national strategies.7
In response to the unmet burden of surgical need, a growing number of countries have been developing National Surgical, Obstetric and Anaesthesia Plans (NSOAPs). These plans are Ministry of Health-led national health policies aimed to ensure that surgical, obstetric and anaesthesia services are available for an increasing number of people through supporting the planning of health workforce and infrastructure capacity.7 As of June 2020, seven countries have developed national-level policies, including Ethiopia, Nigeria, Madagascar, Rwanda, Senegal, Tanzania and Zambia. Over 20 additional countries have made initial commitments to start the NSOAP planning process or are in various stages of development.11 The process of NSOAP planning is adaptable to the local setting and resources of each country and designed to address the unique interplay of population-specific surgical needs within the existing healthcare structure. The NSOAPs are intended to be fully integrated into the national health planning strategy. Although designed to improve access to surgical care for patients of all ages, including language specific for children’s surgery, they may represent an opportunity to address the unique challenges when providing children’s surgical care.
In this study, we assess the inclusion of children’s surgical care among existing NSOAPs and develop a framework based on the GICS OReCS to guide inclusion of children’s surgery in future policies.
Methodology
Applying a health policy analysis framework to global children’s surgery
To assess the degree of inclusion of children’s surgical care within existing NSOAPs, we applied a health policy analysis approach, including two separate qualitative content analyses. We first developed a framework for the analysis, and consequently performed an individual policy analysis of each published NSOAP.
We analysed the GICS OReCS document and the six publicly available NSOAPs at the time of writing through a systematic classification process that supports the identification of themes and patterns and the consequent coding and evaluating of these.12 A similar method has been used to perform a qualitative policy content analysis on subnational insect pollinator legislation in the USA.13 We collected the NSOAPs of Ethiopia, Nigeria, Rwanda, Tanzania and Zambia from publicly accessible websites (eg, from national ministries). Through the GICS network, we additionally received access to the NSOAP of Senegal; we later identified the NSOAP policy on a publicly accessible website. The NSOAPs of Madagascar and Pakistan were not publicly available (as of June 2020), and were therefore not included. Of note, the NSOAP of Pakistan was in the final approval stage at time of writing. The Program in Global Surgery and Social Change (PGSSC) compiles NSOAP policies and related documents on their website.14
Based on Collins’ eight-step framework for health policy analysis,15 we performed the first three steps of the framework in this research. A similar methodological approach has been used in a study analysing asset management policies in Australia.16 Step 1 of the framework defines the context for the policy analysis. In response to the increased focus on the surgical burden of disease, a growing number of countries have developed local ministry-led NSOAPs with support from global partners focusing on the country-specific context (step 1). In step 2, the study collaborators defined the problem following discussions that took place at a previously held GICS meeting: ‘Considering that children make up a significant proportion of the total population in LMICs, to what degree is children’s surgery addressed in these NSOAPs?’. In step 3, we looked for evidence to answer this question by analysing the GICS OReCS document and six NSOAPs.5 This analysis was then used to make recommendations to guide the inclusion of children’s surgery in future policies. We did not perform the further steps of the Collins’ framework, as the NSOAPs are currently in their implementation phases and none have collected benchmarking data so far. The Collins’ framework will allow for the further steps to be completed at a later stage to evaluate the implementation and effectiveness of the policies.
Patient and public involvement
Since this study was designed as a policy content analysis of publicly available documents, we did not involve patients or the public in the design and conduct of the study. The NSOAP development process, however, was led by national ministries and involved elected officials and government representatives as well as various local stakeholder groups, depending on the country setting. It was beyond the scope of our study to analyse country-specific policy processes and the extent various stakeholders were involved in the respective NSOAP process.
Developing a framework based on GICS OReCS
To develop the framework based on the OReCS document, we followed the conventional content analysis approach, without predetermined themes or concepts.12 We used a general inductive approach17 18 with the purpose of deriving themes and patterns from observation in order to capture the frequent, dominant or significant themes described in the OReCS document. For this, one author (SW) closely read the full text of the OReCS document and identified 10 main themes and multiple subthemes. Next, to test the identified themes, this author selected two NSOAPs (Ethiopia and Nigeria) based on the criteria that these were the first NSOAPs alphabetically, written in English language, and had different purposes. The Ethiopian policy was written to address general surgical care, while the Nigerian policy included a section on children’s surgical care specifically. By comparing the identified themes based on the OReCS document and the two NSOAPs, and following multiple rounds of reviews by the other authors, we developed a framework that includes six themes. Those themes were named ‘domains’, and the multiple subthemes for the domains were called ‘key components’ (see graph 1 for the definition of each domain). The modified LCoGS six-component framework for the development of NSOAPs lists ‘governance’ and ‘financing’ as two further domains not addressed in the OReCS document.11 Following consultation with experts from GICS and PGSSC, we included an additional domain called ‘governance and financing’ in the OReCS framework, specifically looking at the inclusion of children’s surgical care in this domain. The domains exist within the wider surgical healthcare system, and graph 1 shows our understanding of how these domains interact and influence one another.
Analysing the NSOAPs and applying the OReCS framework
In the next step, we performed a directed content analysis of the six NSOAPs with the goal to validate or extend conceptually our previously developed framework.12 18 This deductive approach was used to test whether data were consistent with our framework.17 We hypothesised that little was known about the intersection between NSOAPs and children’s surgery. Before conducting the analysis, we developed a standard charting scheme in Microsoft Excel according to the identified domains and key components to support categorising and coding of the data collected from the NSOAPs. To identify areas in the six NSOAPs related to children’s surgery, we conducted a text field search (“child/ren”, “p[a[ediatric”, “age”) and scanned the full text in case we did not capture all references to children. For the Senegalese NSOAP, we performed the analysis in French and later translated the identified text parts into English. One author (SW) first compiled the collected data in a Microsoft Word document and consequently coded it according to the domains and key components of our framework (online supplemental file 1).19 We did not use software for the qualitative analysis due to the small number of documents analysed (GICS OReCS and six NSOAPs), as well as a search focus on themes rather than a defined number of search terms. A second author (PT) scanned the six NSOAPs, as well as the collected and coded data. Discrepancies in coding were resolved by clearly defining the framework domains and resolving differences in data inclusion.
Supplemental material
Results
Overview of NSOAPs analysed
This study analysed the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia. Following the conventional analysis approach, we adapted six domains from the GICS OReCS document and one domain from the LCoGS six-component framework for NSOAPs to guide our review of existing NSOAPs and policy documents (graph 1). Table 1 provides an overview of the OReCS framework domains addressed in the respective policies.
Human resources, workforce and training
The NSOAPs of Ethiopia, Nigeria, Senegal, Tanzania and Zambia addressed the human resources for children’s surgical care. The need for additional paediatric surgeons was noted by Nigeria and Zambia. Additionally, Nigeria specified the number of paediatric nurses and Zambia included children’s anaesthesia providers.
Nigeria, Rwanda, Tanzania and Zambia included training objectives specifically addressing the surgical care of children (table 2). Rwanda expressed the need to develop specialty training programmes. Tanzania aimed to decrease financial barriers to enter training, especially in rural areas. Tanzania and Zambia mentioned training objectives for the recognition of surgical conditions, while Nigeria, Tanzania and Zambia addressed objectives for skills training. Nigeria included guidelines and protocols; further, Nigeria and Tanzania mentioned training for the referral procedure.
Infrastructure
All six countries included an outline of their respective surgical healthcare system infrastructure (online supplemental table 1). Nigeria included non-governmental facilities in the overview. Zambia labelled the facility types as levels without specifying these further. None of the six countries mentioned an existing national children’s hospital in their respective NSOAP; however, Nigeria mentioned the establishment of national and regional children’s hospitals. Nigeria also outlined strategies to increase capacity for advanced surgical care and intensive care at third-level facilities, while Zambia included level 2 and level 3 facilities. Nigeria further addressed transportation and the equipment of ambulances for children (table 2).
Supplemental material
Service delivery
The NSOAPs of Ethiopia, Nigeria, Tanzania and Zambia outlined tasks and responsibilities for healthcare facilities (figure 1). Nigeria covered children’s surgical care for each facility type, bearing the largest resemblance with the recommendations outlined in the OReCS document. Ethiopia and Zambia mentioned tasks and responsibilities addressing children’s surgical care for one and Tanzania for two types of healthcare facilities; these are outlined combined with adult surgical care in their policies.
Nigeria further outlined strategies for all four key components of children-specific service delivery, including an essential surgical package at all facilities, advanced surgical care at tertiary facilities, an efficient referral system based on OReCS, and the integration of care into the transportation and referral system. Zambia planned to increase the number of level 2 and 3 facilities providing surgery and anaesthesia for children (table 2).
Equipment and supplies
Nigeria addressed children-specific equipment, consumables and supply chain management (table 2).
Research, evaluation and quality improvement
Ethiopia, Nigeria and Zambia mentioned quality improvement strategies in their respective NSOAPs. None of the NSOAPs mentioned children-specific research (table 2).
Advocacy and awareness
The NSOAP of Ethiopia outlined an awareness strategy for the surgical care of children targeting healthcare workers (table 2).
Governance and financing
The Nigerian NSOAP addressed children’s surgical care as a separate component from adult surgical care. It also included a section on healthcare governance and leadership specifically addressing children’s surgery, which entails strategic targets, activities and responsibilities, as well as means of measuring the implementation. Tanzania and Zambia listed costs to train paediatric surgeons; in addition, Tanzania specified the costs for skills training. Nigeria stated that specific funding for children’s surgery is not available.
Discussion
NSOAPs have emerged as a viable path to coordinate national efforts to improve surgical, obstetric and anaesthesia care in LMICs. Despite the intent of the analysed NSOAPs to include all surgical care, the surgical care of children, who constitute a large proportion of the population in many LMICs, does not receive sufficient attention. Our findings suggest that all six NSOAPs addressed two or more domains outlined in the OReCS framework. These were, however, often combined with adult surgical care and got lost in typically adult objectives and recommendations that were not specific to the unique needs of children. Rather, children’s surgery should be included as an integral and specific component of NSOAPs, and addressed separately to adult surgical care (box 1 provides recommendations for the inclusion of children’s surgery in NSOAP policies).
Recommendations for the inclusion of children’s surgical care in NSOAP policies
General
Identify regional and national paediatric surgical societies who can act as stakeholders in the process of strategic planning.
Include at least one paediatric surgeon during the NSOAP process.
Perform children-focused needs assessment prior to developing an NSOAP (see GICS WHO-PGSSC assessment tool).
Address the unique surgical needs of children as a separate component from adult surgical care in the NSOAP.
Human resources and training
Establish existing and needed human resources and specifically include paediatric anaesthesia and nursing care.
Clearly outline training objectives for all types of healthcare facilities.41
Infrastructure
Clearly outline the surgical care system for children and clarify the level of care for each healthcare facility type in order to optimise triage.
Use a needs-based assessment for optimising location of healthcare facilities with paediatric surgical capabilities.
Service delivery
Outline tasks and responsibilities for the various types of healthcare facilities; refer to the GICS OReCS document for guidance.
Identify or develop a regional triage system for surgical patients including organised referral centres and patient transport agencies.
Equipment and supplies
Perform facility-level assessments of existing paediatric facilities to determine ways to optimise delivery of paediatric surgical care in these facilities using the GICS tool.42
Research, evaluation and quality improvement
Establish a local research team with the mission to examine the delivery of paediatric surgical care and monitor implementation.
Research objectives for various levels of healthcare facilities that can be found in the GICS OReCS document.41
Governance and financing (derived from LCoGS six-component framework for NSOAPs)
Specify implementation and accountability mechanisms and establish strong leadership.
Include means of measuring progress and achieving set targets (eg, annual reports, progress tracker).
Allocate resources specifically to the surgical care of children.
GICS, Global Initiative for Children’s Surgery; LCoGS, Lancet Commission on Global Surgery; NSOAPs, National Surgical, Obstetric and Anaesthesia Plans; OReCS, Optimal Resources for Children's Surgery; PGSSC, Program in Global Surgery and Social Change.
A number of countries performed a surgical needs assessment prior to the development of their NSOAP. Nigeria performed a children-specific needs assessment and also included paediatric nursing care, using a children’s surgical assessment tool developed by GICS and PGSSC based on the WHO assessment tool.20 Children-specific needs assessments support the mapping of available human resources and infrastructure for children, which are currently not widely established. Three further capacity assessment tools for children’s surgery have been identified,21 of which the Pediatric Surgery Personnel, Infrastructure, Procedure, Equipment and Supplies Survey was developed specifically for LMICs to assess paediatric surgical capacity in West Africa.22 Robust needs assessments with respect to children’s surgical care are critical to ensure that the needs of children are met while developing NSOAPs.
Scaling up capacity for children’s surgical care
Due to the specialised nature of children’s surgical care, specific infrastructure needs are required to ensure high-quality children’s surgical care. However, the majority of hospitals in LMIC settings lack capabilities to provide for children with critical injury and illness.23 The 30-day mortality for abdominal emergency surgery in LMICs was highest in neonates and decreased with increasing age.24 Younger children, especially neonates and infants, are a particularly critical group, requiring more complex and specialised surgical health services. In comparison, surgical care for older children is more amenable to task shifting with adult surgeons performing operations and treating children in this age group.25 Nevertheless, children of all ages undergoing emergency surgery had better outcomes when managed by children’s surgeons, emphasising the importance of developing children’s surgical capacity.26
Shortages of equipment and resources are further issues, with neonatal intensive care units or general intensive care units available in only about half of the tertiary facilities surveyed in West Africa.22 Moreover, a study on paediatric surgical capacity in Africa found that burn units were not available in Senegal and Zambia.27 The OReCS framework highlights the need for at least one specialised children’s facility in each country, and additional infrastructure to ensure a robust regional triage system for complex paediatric surgical patients. In Brazil, for example, geographical access to children’s surgical care varies widely, which shows the need for coordinated efforts to paediatric facility placement.28 We found that none of the six countries analysed mentioned an existing national children’s hospital; however, Nigeria’s policy called for the establishment of national and regional children’s hospitals. Zambia additionally called for an increase in the number of tertiary referral hospitals. This represents a way for national governments to help coordinate the construction of children’s hospitals in locations that are optimal for care provision. Further work mapping geographical access to surgery could help optimise the placement of these types of healthcare facilities.
The need to address workforce shortages
Shortages of trained workforce among all types of healthcare workers are prevalent in LMICs.22 Eight African countries with 185 million children under the age of 15 years reported 231 children’s surgeons.3 Nigeria had 1.1 paediatric surgeons per million children, while Malawi had 0.17 per million children; in comparison, the USA had 20.5 paediatric surgeons per million children.3 In a countrywide survey conducted in Sierra Leone, 17.6% of children reported a potentially treatable surgical condition, yet, the country had no registered paediatric surgeon.29 Moreover, the number of facilities providing surgical care for children is insufficient to meet the need, with a geographical distribution skewed towards urban areas. Nearly 90% of the health workforce trained in paediatric care is located in large tertiary hospitals primarily situated in urban areas, while 75% of the population lives in rural areas.30 31 Factors such as a lack of funding, limited training opportunities and insufficient political support have been identified.5 The NSOAPs of Nigeria, Rwanda and Zambia specifically addressed the need for additional children’s surgeons through increased training, decreasing financial barriers for trainees and standardising skills training. These efforts can act as a roadmap for other countries embarking on NSOAPs and aiming to expand the size of their children’s surgical workforce. In addition, however, there is a need for programmes that support rural surgeons and those who practise outside of large urban areas. This can help improve access to care for rural populations, especially in countries with limited interfacility transport systems in place.
Governance and financing of children’s surgical care
Governance has recently been added as a sixth framework component for NSOAPs as previously outlined by the LCoGS.1 11 Zambia performed a stakeholder analysis in their NSOAP, while Nigeria’s policy addressed the surgical care of children as a component separate from adult surgical care. These examples highlight the importance of involving children’s surgery providers in the development process to ensure the surgical needs of children are addressed accordingly. A roadmap for including children’s surgery in the NSOAP planning process is available.32 To ensure accountability, specific targets and means of measuring these need to be included and reported on regularly. This can be, for instance, in the form of annual reports or a progress tracker. Tanzania and Zambia included budget plans specifically addressing training for children’s surgical care, which listed costs to train children’s surgeons; additionally, Tanzania specified the costs for skills training. From a health economic perspective, surgical care for children is cost-effective and provides potential long-term economic and social benefits, considering that these interventions take place at a young age.33 The overall burden of disease is measured using disability-adjusted life years (DALYs), which combines the number of years lost due to ill-health, disability or premature death. For example, surgery for cleft lip and palate repair (US$47.74 per DALY) is more cost-effective compared with HIV treatment (US$453.74–US$648.20 per DALY),34 while paediatric inguinal hernia repair (US$12.41 per DALY) is more cost-effective compared with insecticide-treated bed nets to prevent malaria (US$41 per DALY).35 Cost-effectiveness analysis can aid the comparison of the relative costs of different interventions, which in the case of children’s surgical interventions can avert long-term disability and the need for medical care in the future. Further research will be needed to support evidence-based priority setting in the local context and the consequent allocation of resources.
Limitations
This study contains several limitations. There are a variety of health policy analysis frameworks, and the authors used the Collins’ framework for its simplicity and familiarity. Policy formulation is not a linear process that can be separated into several domains, but rather an evolving and integrated process that involves input from various stakeholders and undergoes multiple rounds of discussion. Using a framework approach for the analysis makes it seem that the framework domains do not interact; however, the domains are all connected in the wider surgical healthcare system and integral for its functioning. For example, increasing infrastructure without adequate staffing will not lead to improved care, nor the other way around. Standalone domains do not allow for an evaluation and understanding of the processes of the policy development and implementation, and which domains are necessary for others to evolve. Figure 2 visualises how these domains interact in the wider healthcare system (figure 2); however, due to a lack of evidence, the figure is based on the authors’ understanding and experiences and requires further research. Biases in the selection process of the domains may have been involved due to one researcher reading the OReCS document in detail and selecting the initial themes for the framework. In addition, the scope of our study was not designed to include key provider aspects such as the financing of healthcare and healthcare facilities, nor user aspects such as insurance coverage and patient-specific factors. We applied a standardised framework to code and analyse the NSOAP policies, whereas the NSOAP process is not standardised. Our analysis possibly missed crucial information on structures and resources that are available but not mentioned in the NSOAPs, such as paediatric workforce numbers in countries. The OReCS document was developed to provide guidance for developing children-focused NSOAPs; however, recognising and prioritising the unique surgical needs of children are currently not widely established. As this study only included information that specifically referred to children, it likely under-reported on strategies that included, but did not name children. Additionally, we identified two further NSOAPs that have been completed but are not yet available for review, namely of Madagascar and Pakistan. These policies warrant further analysis in the future.
Conclusion
This study highlights practice examples for the inclusion of children’s surgical care in NSOAPs and provides recommendations based on the GICS OReCS framework for the development of future policies. The OReCS framework can be used to assist planning on a national level in settings where children’s surgical care is included in the national surgical, obstetric and anaesthesia process.
Data availability statement
Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplemental information. All data relevant to the study are publicly available and are included in the article or uploaded as supplemental material.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was not required as the study only included publicly available documents and information.
Acknowledgments
SW acknowledges financial support from the Studienstiftung des deutschen Volkes (German Academic Scholarship Foundation). The authors would kindly like to thank Nishali Patel and Sarai Keestra for providing feedback on earlier versions of the manuscript.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @ptrucheMD, @johnmeara
Contributors SW and DP conceived of the study and act as guarantors. Conceptualisation—SW, EG and DP. Methodology—SW, EG and DP. Data curation—SW and PT. Formal analysis—SW, PT, LS, JM and DP. Writing (original draft)—SW and PT. Writing (review and editing)—SW, PT, EA, LS, EMMM, SG, EG, JM, THvD and DP. SW and DP conceived the study and act as guarantors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.