title: Barriers to the uptake of laparoscopic surgery in a lower-middle-income country.
abstract: BACKGROUND
  Despite the significant improvements in surgical care in developed countries, the adoption of laparoscopy in lower-middle-income countries (LMICs) has been sporadic and minimal. Although the most quoted explanation for this has been an apparent lack of resources and training, recent studies have demonstrated that these constraints may not be the only significant barrier. The overall aim of this study was to analyze barriers to the adoption of laparoscopic surgery at a hospital in an LMIC.
  
  
  METHODS
  Using an exploratory case study design, this investigation identified barriers to the adoption of laparoscopic surgery in an LMIC. More than 600 hours of participant observation as well as 13 in-depth interviews and document analyses were collected over a 12-week period.
  
  
  RESULTS
  Three overarching barriers emerged from the data: (1) the organizational structure for funding laparoscopic procedures, (2) the hierarchical nature of the local surgical culture, and (3) the expertise and skills associated with a change in practice. The description of the first barrier shows how the ongoing funding structure, rather than upfront costs, of the laparoscopic program limited the number of laparoscopic cases. The description of the second barrier highlights the importance of understanding the local surgical culture in attempts to adopt new technology. The description of the third barrier emphasizes the fact that due to the generalist nature of surgical practice, surgeons were less willing to practice more technically complicated and time-consuming procedures.
  
  
  CONCLUSIONS
  This exploratory case study examining the barriers hindering the adoption of laparoscopy in an LMIC represents a novel approach to addressing issues that have plagued surgeons across LMICs for many years. These findings not only further understanding of how to improve the adoption of laparoscopy in LMICs but also challenge the economic-centric notions of the problems that affect the transfer of innovation across social, economic, and geographic boundaries.
authors.affiliation: Department of Surgery, University of Toronto, 22 Wellesley St East, Suite 1508, Toronto, ON, M4Y 1G3, Canada, ian.choy@utoronto.ca.
authors.forename: Ian
authors.initials: I
authors.lastname: Choy
authors.forename: Simon
authors.initials: S
authors.lastname: Kitto
authors.forename: Nii
authors.initials: N
authors.lastname: Adu-Aryee
authors.forename: Allan
authors.initials: A
authors.lastname: Okrainec
mesh_terms: D000354:Africa, Western; D002202:Capital Financing / Q000458:organization & administration; D002983:Clinical Competence; D003469:Culture; D018588:Fee-for-Service Plans / Q000458:organization & administration; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D010535:Laparoscopy / Q000191:economics* / Q000193:education / Q000706:statistics & numerical data*; D016730:Program Development; D012959:Socioeconomic Factors; D013503:Surgery Department, Hospital / Q000458:organization & administration*