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Table 1 Barriers to surgery performed by NPCs in SSA identified in the literature

From: Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa—a scoping review

Main category of barriers Sub-category Type of barrier Barriers to surgery performed by NPC identified in the literature (n = number of articles mentioning the barrier) Corresponding references by study types
Empirical (N = 45) References Non-empirical (N = 17) References
I. Primary outcomes (28 articles) 1. Surgical output A.1 Range and volume of surgical procedures performed by NPC 1. Inadequate surgical skills (n = 8) (n = 3) [14,15,16] (n = 5) [17,18,19,20,21]
   2. Inadequate diagnostic skills (n = 6) (n = 3) [22,23,24] (n = 3) [18, 25, 26]
   3. Insufficient opportunities to practise after training (n = 2) (n = 1) [27] (n = 1) [17]
2. Surgical outcome A.2 Surgical outcomes of surgical procedures performed by NPC 4. Low-quality care of NPC, without comparison to MD (n = 9) (n = 8) [15, 28,29,30,31,32,33,34] (n = 1) [18]
   5. Worse surgical outcome compared to MD (n = 4) (n = 2) [35, 36] (n = 2) [37, 38]
3. Surgical information A.3 Availability and quality of information on surgical output/outcomes 6. Ambiguous or incomplete evidence on NPC (n = 8) (n = 5) [27, 31, 36, 39, 40] (n = 3) [2, 17, 25]
II. NPC workforce (40 articles) 4. Training B.1 Quality and amount of education and training 8. Inadequate pre/in-service training in basic surgical operations (n = 10) (n = 8) [14,15,16, 30, 35, 41,42,43] (n = 2) [18, 44]
   9. Insufficient opportunities for practising during training; inappropriate practice setting (n = 6) (n = 3) [14, 27, 45] (n = 3) [2, 25, 46]
   10. Inadequate infrastructure or supplies at training facilities (n = 4) (n = 4) [42, 47,48,49] - -
  B.2 Standardization 11. Poor coordination of training (n = 9) (n = 4) [14, 15, 27, 40] (n = 5) [19,20,21, 25, 50]
  B.3 Financial support 12. High expenses and inadequate funding for training or education (n = 4) (n = 2) [30, 45] (n = 2) [2, 8]
5. Supervision in the field B.4 Availability of supervision and support for supervision 13. Poor quality of supervision (n = 2) (n = 2) [15, 40]
   14. Lack of (financial) support and availability of MD for supervision (n = 8) (n = 7) [14, 22, 30, 47, 51,52,53] (n = 1) [50]
6. Composition of surgical team B.5 Availability of team members 15. Staff shortages (n = 12) (n = 11) [14, 15, 24, 27, 40, 42, 49, 54,55,56,57] (n = 1) [25]
7. Career development B.6 Career path 16. Absence of career progression (n = 10) (n = 6) [14, 27, 58,59,60,61] (n = 4) [2, 18, 19, 25]
   17. Behavioural problems due to lack of career progression (n = 4) (n = 3) [14, 30, 59] (n = 1) [21]
8. Employment conditions B.7 Remuneration 18. Insufficient remuneration (n = 8) (n = 7) [14, 27, 30, 54, 58, 60, 62] (n = 1) [2]
   19. Financial competition between MD and NPC (n = 2) (n = 1) [51] (n = 1) [8]
  B.8 Prestige, professional status 20. Insufficient professional recognition or status (n = 4) (n = 4) [14, 60,61,62]
9. Workload B.9 Burden of work 21. High workload (n = 7) (n = 5) [14, 15, 30, 51, 52] (n = 2) [2, 19]
10. Retention B.10 Retention at rural level 22. Difficulties to retain at rural level (n = 6) (n = 3) [22, 30, 47] (n = 3) [17,18,19]
III. Regulation (27 articles) 11. Regulation C.1 NPC professional profile 23. Absence of a standardized, legal framework for NPC (n = 15) (n = 10) [14, 30, 33, 34, 40, 41, 51, 52, 58, 63] (n = 5) [8, 19, 25, 64, 65]
  C.2 Coordination 24. Inadequate coordination and support of NPC practising surgery (n = 7) (n = 3) [27, 30, 40] (n = 4) [2, 18, 25, 50]
   25. Absence of a regulating body for NPC (n = 3) (n = 2) [58, 61] (n = 1) [64]
   26. Unsuitable clinical protocols (n = 4) (n = 3) [15, 40, 51] (n = 1) [64]
12. Acceptability C.3 Attitudes of policymakers, health workers, and patients towards NPC 27. General resistance (n = 16) (n = 8) [14, 27, 30, 47, 52, 53, 59, 61] (n = 8) [2, 8, 19, 25, 46, 64,65,66]
   28. Fear for loss of power by MD; competition between MD and NPC (n = 8) (n = 5) [22, 27, 34, 52, 59] (n = 3) [2, 8, 25]
   29. Concerns on quality of care, ethical reservations (n = 7) (n = 4) [14, 30, 52, 59] (n = 3) [2, 20, 64]
  C.4 Attitude of NPC themselves 30. Negative attitude of NPC (n = 4) (n = 2) [14, 52] (n = 2) [2, 25]
IV. Environment and resources (26 articles) 13. Infrastructure and supplies D.1 Availability of infrastructure, basic amenities, and equipment 31. Inadequate theatre rooms (n = 4) (n = 4) [27, 47, 52, 57]
   32. Challenging environmental factors (n = 4) (n = 4) [55, 58, 67, 68]
   33. Shortages of equipment (n = 13) (n = 11) [15, 22, 30, 40,41,42, 47,48,49, 57, 69] (n = 2) [17, 25]
  D.2 Availability of supplies 34. Supply shortages (n = 10) (n = 8) [30, 40, 47, 48, 54, 55, 63, 69] (n = 2) [17, 19]
14. Health information system D.3 Availability/quality of health information systems 35. Insufficient data recording systems (n = 5) (n = 4) [52, 70,71,72] (n = 1) [64]
Total number of times barriers are mentioned in 62 reviewed articles 160   73