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21 How toBuild anAcademic Global Surgery Center: TheUCSF CHESA Experience
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How toBuild Research inLow-
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andMiddle-Income Countries
TheresaChin andNiaZalamea
Research is formalized curiosity. It is poking and prying with a purpose.
– Zora Neale Hurston
Abbreviations
HICs High-income countries
IRB Institutional Review Board
LMICs Low- and middle-income countries
QI Quality improvement
WHO World Health Organization
Background
Quality improvement (QI) and research are
intertwined; they are similar in underlying
concept of expanding knowledge, yet they differ
in their specic goals (Table 22.1). Quality
improvement focuses on the delivery of health
care by implementing knowledge or evaluating a
process or program, whereas research answers a
question or hypothesis to create new knowledge
that can be generalizable to a population [1, 2]. In
QI, patients are subject to new initiatives as an
T. Chin (*)
University of California Irvine, Orange, CA, USA
e-mail: chintl1@hs.uci.edu
N. Zalamea
University of Tennessee Health Science Center,
Global Surgery Institute, Memphis, TN, USA
e-mail: nzalamea@uthsc.edu
22
inherent result of consenting to healthcare
delivery, and protocols are adapted to a given
healthcare system and adjusted therein to make
improvements. On the contrary, in research,
patients may be randomized to avert confounding
data, or there may be a xed protocol with a
predened population and methodology to avert
bias when interpreting data. Research may be
qualitative or quantitative and can include
investigating processes or programs for
generalizable knowledge for evidence-based
medicine. QI initiatives can become research,
and research methodologies can be used in
quality improvement. When QI projects evolve
and become research, ethical approval of the
research is necessary to protect human subjects.
Creating a research program requires strategic
planning and support, as it is an endeavor that
cannot be done successfully alone. It will require
time, effort, nancial investment, and advocacy.
This chapter is a framework from which to
develop a research program (Table 22.2 and
Fig. 22.1). It can be customized for building
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_22
247
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Table 22.1 Comparison of quality improvement and research
Quality improvement Research
Goal • Implement knowledge
• Evaluate a program or process
• Improve healthcare delivery
Risk • No increased risk to patients, except
possible breach of personal health
information
Typical methodology • Compares program, process, or system
change to current or conventional
standard
Knowledge • Implements existing knowledge to
improve care
Table 22.2 Framework for building research capacity in LMICs
What is the current capacity for research? • Knowledge of research methodology
• Capability to do basic, translational, clinical, or outcomes research
• Priority of research within the context of the healthcare system
• Ofce or laboratory space, equipment, and supplies
• Personnel resources (Translation services, biostatisticians)
• Clinical and data services
• Availability of an ethics committee or Institutional Review Board
• Current data sources (medical record documentation, available
registries)
Who are the stakeholders at your institution
or community?
What collaborations or partnerships can be
developed?
What to consider in a strategic plan? • Support and completion of existing projects and other early
• Hospital leaders
• Department or academic leaders
• Nursing/Allied health representatives
• Public health experts
• Scientists
• Government and nongovernment leaders
• Twinning models of institutional partnership
• Regional or national collaborations
• Nongovernmental organization partnerships
• Medical society collaborations
• Interdepartment collaborations
• Industry or corporate partnerships
successes to positively reinforce the potential of the program
• Strategies to create tangible value early in the plan (grant funding,
nancial support from partner institutions, salary or time support
from department leaders or partners, etc.)
• Research ideas or methods that lead to subsequent projects
• Win-win projects where all partners/collaborators benet
• Anticipation of potential failures and ways to avert them
• Create a system of mentorship as it will encourage and train new
researchers for sustainability and expansion
• Develop a clear, simple action plan
• Produce to generalizable
knowledge
• Test a hypothesis
• Answer a specic question
• May have increased risk
• Aimed to answer question or test
hypothesis
• Can be retrospective or prospective
• Can be observational or
interventional
• Creates new knowledge or
evidence
T. Chin and N. Zalamea
22 How toBuild Research inLow- andMiddle-Income Countries
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Table 22.2 (continued)
What ethical issues should be considered
throughout the program development?
What to consider when implementing the
action plan?
How to assess progress and modify for
improvement or expansion?
• Autonomy, benecence, nonmalecence for all research subjects
• Equitable authorship
• Equity and transparency in partnerships and collaborations
• Adequate nancial compensation for research efforts
• Management of the grant money and its disbursement in twinning
partnerships
• Local or cultural adjustments to the community
• Systematic and unconscious biases
• Timeline and milestones
• Scheduled reassessments
• Realistic priorities
• Available funding
• Team feedback
• External feedback
249
Define the barriers and gaps
to building research capacity
Assess current
capacity for research
Assess progress
and modify for
improvement
or expansion
Implement action
plan
Fig. 22.1 Research program development
Prioritize aims and
goals
Develop a
strategic action
plan
research capacity in LMICs and should be tailored to t the local environment. The process of
assessing need, dening aims and goals, and creating a strategic plan is dynamic and may change
as new needs are identied, new ideas and goals
are developed, and the strategic plan consequently changes. The leadership of any research
program should be goal-oriented yet exible.
Investigate existing programs
and current stakeholders
Identify available
resources/potential
partners/collaborators/
funding opportunities
Ethical Pitfalls:
Inequitable authorship
Lack of respect for cultural norms
Partnership and collaborative equity
Lack of transparency
Exclusion rather than inclusion
Systematic and unconscious biases
A Framework forDeveloping
Research inanLMIC
What Is theCurrent Capacity
forResearch?
A needs assessment gathers information to
examine the current system and capacity for
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T. Chin and N. Zalamea
research in its current state. It is like doing an
inventory in a store and allows the store owner to
see which items are lacking. Someone who
knows the local environment is vital to the needs
assessment. Similarly, an inventory of a store is
best done by workers in the store who know
where every item is stored or displayed. Below
are items to include in a broad assessment of
research capacity of a given system and may not
be completely comprehensive in all settings.
Table 22.3 has a basic checklist of needs for a
research program.
• Knowledge of research methodology: Are the
researchers knowledgeable in study design and
able to dene a research question? Is it a research
question that is applicable to the local population? Is it culturally and ethically feasible?
• Capability to do basic, translational, clinical,
or outcomes research: clinical outcomes
research as well as retrospective and prospective observational trials are frequently easier
to start than basic science and translational
research. Basic science and translational
research may require testing or equipment not
readily available in the clinical setting, such as
polymerase chain reaction tests or other
assays.
• Priority of research within the context of the
healthcare system: Does the culture of the leadership and staff to prioritize research enough to
contribute to the efforts? Research in a clinical
setting requires additional time and effort
beyond typical duties of clinician. Will the
institution or department compensate the fac-
Table 22.3 Basic checklist of needs for research
programs
1. Leader(s) of research efforts and/or principal
investigator
2. Team member(s) knowledgeable in research
methods and study design
3. Team members(s) to enroll and follow up
patients and collect data
4. Team member(s) to manage the data, analyze,
and interpret the data
5. Ethical board or institutional review board
(IRB)
6.Equipment and supplies
7.Access to existing literature
ulty to conduct research in either time or
money? Will the local leadership advocate for
research efforts to local government ofcials?
Will the institutions be able to obtain access to
research to improve the quality of care delivered? Is research required for faculty advancement? What are the metrics that are measured?
• Ofce or laboratory space, equipment, and
supplies: Space can be shared or used for
research and clinical obligations. Equipment
and supplies include ofce equipment, computers, laboratory equipment, and consumable
supplies/materials.
• Personnel resources: Research assistants, data
manager or analyst, and clerical staff are frequently needed. People can fulll multiple
roles, but additional funding for personnel
will improve the efciency of the research as
personnel specic for the research program
can dedicate time to the project(s). If researchers are interested in publishing in journals that
are in English, interpreter and translation services, though costly, may be necessary.
• Clinical and data services: Collaborating with
the clinical lab can allow for more efcient
work ow. Statistical assistance may be available in the school of public health. Data services may be available through the hospital
system. The WHO has data registries available
to LMICs such as burn or trauma. In countries
looking to publish in a language that is not
native, hiring of an interpreter and translator
may be a previously unforeseen cost.
• An ethics committee or Institutional Review
Board: to review research studies to ensure all
research is conducted in an ethical manner.
• Current data sources: Does the medical record
documentation have adequate detail and legibility (if paper) where a retrospective study
could be performed? Does the healthcare
system and cultural norms allow for patients
to be followed prospectively?
Who Are theStakeholders at your
Institution or Region?
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251
Stakeholders are people who have a vested
interest in the program and are important to the
success of a research program. Local institutional
leadership is essential to a sustainable research
program because they are familiar with the culture, the local administration, and the feasibility
within the local system. They may be leaders
within the hospital, the department, or the academic institution. Support from the administration and local leaders helps to gain resources for
the research program. These leaders can advocate
and allocate resources for research.
Administration and other leaders can work with
editors of regional or international journals for
equitable publishing and promotion.
Inclusion of other disciplines such as nursing
or other allied health professions will improve
the success of the research project and program
and provide different perspectives for feasibility
of select research studies. For example, public
health faculty may be able to provide assistance
for statistics or study design and, in exchange,
authorship on research can benet the faculty for
academic promotion. Consider who may be
affected by the research protocol. Think about
nurses, pharmacist, other medical disciplines,
and administration, information technology,
equipment personnel, laboratory personnel. To
be inclusive and culturally appropriate, representatives for all populations that are affected by
research should be included in the research
board. For example, if the study includes or
affects indigenous populations, a representative
of that population should be included in the
study design and/or ethics board. It is helpful to
include stakeholders early in the study design
period or research program planning to maximize efciency for study recruitment, enrollment, consent, data collection, and program
development.
Investigate existing programs at the institution
or local region. Learn from other programs that
have thrived in similar environments. Sometimes,
one may nd that there are other people with
similar interests at the same institution. In addition to available resources in the local area, there
are many resources that are free or available at
low cost on the Internet. Explore journals that
have open access. Many institutions have free
educational classes and webinars related to
research. Many statistical programs that can be
used for data analysis require a fee, but a few
products are free and open access. Basic statistics
can be calculated within a spreadsheet application, such as Microsoft Excel or Google Sheets.
Advanced data analysis and interpretation often
require additional training; however, collaboration with statisticians can bridge the gap and provide additional resources.
Develop aStrategic Plan
foraResearch Program
• A thoughtful strategic plan can be worth the
investment over time. It can make the entire
program more efcient, and creation of contingency plans can improve the potential for
success. The basic checklist of needs in
Table 22.3 will give you the necessary elements to get started.
• Identify early projects that can lead to other
projects and continued research such as a
dataset that can be used to answer more than
one question. Projects that are “low-hanging
fruit” and likely to be successful early on will
be positive reinforcement for continued
research efforts and support. These projects
may be simpler in research methodology or
already in progress. Publishing interesting
case reports demonstrates an interest in the
science of surgery and can lead to research
topics or ideas. It will also introduce the complexities of submitting and revising a manuscript for publication.
• Many research questions arise from daily
routine care for patients. There may be some
clinical research projects in progress with
basic data collection and tracking of patients.
Consider investigating patterns of disease, a
new or alternative intervention, a different
population, patient outcomes, or efcacy of
clinician behaviors. Conduct a literature
review and see if your question is already
answered. Is the existing literature generalizable to low- and middle-income health sys-
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tems and populations? Are you identifying the
problem or developing solutions to the problem? Is there another clinical question within
a different population or subgroup?
• With new collaborations or partnerships,
consider starting with projects where all
involved benet to be positive reinforcement
to working together.
• Do others think the research idea is a good
one that will have impact? What personnel
is available to assist in your research? You
may revisit this item throughout the research
project. Seek help. Look for collaborations
and mentorship. Find a local champion if you
can’t do it yourself.
• Are there personnel adequately trained in
study design who can assist with creating
studies? If not, consider expanding your
search to identify potential collaborators or
people who are willing to learn and train.
• Formulate a data management plan. This is
to ensure that data, especially if it contains
personal health information, is secure and
protects patients and research subjects.
Additionally, contingency plans to avert
lost data either digitally or papers should be
created. Electronic collection tools make it
easier to analyze the data; however, paper
collection tools may allow for ease of data
collection, particularly if computers or tablets
are not easily accessible or available. Paper
collection tools can be more arduous since the
data on the paper will need to be inputted to
a computer program to be analyzed. This can
lead to potential human errors in data entry.
Aim to maintain the original data in the LMIC
where the data is collected.
• Prioritize mentorship, because it is important
to encourage new researchers to persevere
early in their research career when successes
are small or infrequent. Mentors can guide
faculty on how to present and publish research
or quality improvement projects. Mentors
can be from the local LMIC institution and/
or from partnering or HIC institutions.
Tele- mentorship can help with advancing
research in LMICs, provided both parties are
engaged and invested in the research project.
Local mentorship is ideal as the mentor will
understand the local infrastructure, system,
and culture. Furthermore, engagement may be
more sustainable with a local mentor.
• Create clear and simple action items as part
of your strategic plan. This will help you
monitor progress and allow the project to
move forward.
Ethical Considerations
There are several ethical issues specic to LMICs.
It is extremely important to maintain the highest
ethical conscience to protect people and cultural
communities and to preserve relationships and
partnerships. Chapters 3 and 36 in this book
focus on the ethical issues of both practice and of
research in LMICs,
• The three principles of basic human subject
research apply to all research regardless of
geographic location or socioeconomic status:
1. Autonomy: LMIC communities and
patients should be able to make informed
decisions about what is best for their
communities and themselves.
2. Benecence: There should be benet to the
population of the LMIC either directly to
the patients or to society.
3. Non-malecence: As possible, tactics
to minimize risk to the community and
individual patients should be employed.
• Credit and authorship for research efforts
must be equitable and can be used to edify
LMIC researchers. Some LMIC researchers
are promoted based on publications, and their
efforts should be considered. Strategies to
ensure equitable authorship are described in
the consensus statement by Morton et al. [3]
and can include expectation of rst or senior
authorship from the initiation of the research
project, structural reexivity statements
to describe how equity was maintained
throughout the study, and adaptations to journal
requirements that promote equity. Authorship
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can be discussed early in the project when the
expectations of the LMIC and HIC partners are
established.
• When researchers from high-income countries
conduct research in a LMIC, early inclusion
and heavy involvement of local LMIC personnel are vital to ensure that the research study
confers maximum benet with minimal risk,
in addition to ensuring that the study is culturally appropriate. If available, ethical approval
from both a local LMIC ethical board and the
HIC institution should be obtained.
• Partnerships are a two-way relationship where
both parties contribute resources and benet.
Collaborations occur when individuals or
institutions work separately toward a unied
goal. Both partnerships and collaborations
should be equitable, and the communication
should be bidirectional. In a partnership,
decision- making should be shared, particularly in regard to shared resources. If a HIC
institution or company is more authoritative
and dictates the study plans, the lack of autonomy of the LMIC places those involved with
the research at an increased risk of
vulnerability.
• Access to the data should be equitable and
ideally associated to where the bulk of the data
is collected. Frequently, data is collected in
LMICs but housed in HICs, limiting access to
the data for LMICs for additional research and
quality projects.
• When funding is available, LMIC partners
should be adequately compensated. If the bulk
of the labor is conducted at the LMIC, the
bulk of the funding should be awarded to the
LMIC.
• Addressing the impact of any research on the
local community is essential to the trust of the
community on biomedical research. Consider
if the methodology is feasible with the
resources available and if it inhibits the local
community in other ways. For example, a laboratory test can be conducted for research, but
it may delay or prevent other laboratory tests
necessary for clinical care. Discuss with the
local leaders if the research applicable to the
LMIC setting is impactful for the patient population (i.e., will the research help the local
people/society)?
• Take caution for people who may have
alternative motivations. Some may be political
or nancial. Focus on what is best for the
people and community and take heed to
warnings from others with different
perspectives.
• It can be hard to predict and foresee all
systemic and unconscious biases that we all
have. Regardless, once they come to light,
they should be addressed with the highest
ethical and equitable consideration and respect
for others.
Implement Action Plan
• Successful action plans have timelines and
milestones to keep the project on track. Be
realistic in creating the timeline and milestones so that the program can be successful
and sustainable.
• Schedule regular reassessments. In a new
program, monthly or quarterly assessments
may be needed to keep the program on track.
As the program becomes more established,
yearly review may be adequate to ensure the
needs of all involved are being met.
Assess Progress andModify
forImprovement or Expansion
• Identify funding, if available. Funding is not
required to start research; however, it is needed
to sustain a program. Local institutional and
governmental investment into the research
program is one of the best strategies for sustainable funding. However, funding options
through societies, academic institutions, nonprot organizations, and even industry may
provide an initial launching pad for research
endeavors. Be mindful of conicts of interest.
• Feedback from all members of the team and
community will improve the efciency of the
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T. Chin and N. Zalamea
team and can allow for growth of the program. It
will also identify needs or gaps that may compromise the stability of the program and research
team. There may be new resources or stakeholders available and should be considered. As the
program is successful, it will naturally expand as
others become interested and want to partner or
collaborate. However, take caution to expand too
fast, as research requires time, money, and
material resources that can easily be depleted.
• Feedback from outside sources can generate
ideas for improving efciency and introducing
new resources. Outside sources may include
other local leaders, society leaders, or other
organizations that may have a vested interest in
the population or community.
Conclusion
Research is a collaborative effort and requires
persistence and multiple tries to be successful. Do
not be discouraged! It can take multiple tries and
relies on assembling the right team for success.
Occasionally, merely starting a project and
adapting to the needs of the project can lead to
momentum and others joining and supporting the
effort. It is practically impossible to be prepared
for all aspects of research, so exibility and
adaptability are two qualities that can increase the
success of a research program.
How can researchers in HICs edify LMIC
researchers? Partnerships between institutions in
HICs and LMICs can expand the available
knowledge, experience, and resources to conduct
research. However, the partnership may want to
initially establish boundaries and formalize with
a memorandum of understanding so that all
institutions involved are treated fairly.
References
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