Scaling uptake of ChEETAh trial evidence into practice: Mixed-methods development of an implementation research logic model

Abstract

Introduction: Surgical site infection (SSI) is the most common complication after surgery. The ChEETAh trial demonstrated changing gloves and instruments before closing the abdominal wound reduces SSI rates and is cost-effective. Scaling this intervention is important to bring wider benefits to patients globally. The aim of this study was to co-design an implementation research logic model (IRLM) with stakeholders across low- and middle-income countries (LMICs).

Methods: This mixed-methods study was delivered in three phases. In phase 1, we completed a multicentre cohort study across 81 centres from seven LMICs to determine post-trial implementation rates. In phase 2, we undertook a survey of key stakeholders (surgeons, principal investigators, research staff) to identify barriers and facilitators. In phase 3, we conducted two workshops with the Study Management Group (SMG) to develop and refine the IRLM with key stakeholders.

Results: Overall implementation was 27.0% and was higher in hospitals that had participated in the ChEETAh trial compared to those who did not (38.9% vs 14.4%). In phase 2, the commonest barriers limited available resources such as procurement costs and equipment (46.7%, n=14/30) and executing the intervention complex emergency settings (26.7%, n=8/30). In phase 3, local strategies included (i) integrating the intervention within the WHO checklist; (ii) identifying local champions to monitor and feedback on performance; and (iii) developing a toolkit which includes business cases. National strategies included (i) embedding intervention into national guidelines; and (ii) regional and national-level systems to monitor performance on a regular basis. 

Conclusion: While implementation of the ChEETAh intervention has improved from baseline, it remains inconsistent, especially in hospitals that did not participate in the trial. The gaps in implementation suggest a need for targeted efforts, particularly in non-trial settings. Future initiatives should prioritise stakeholder engagement to co-develop tailored strategies that address local barriers and promote sustainable, system-wide adoption.