Discussion
SSI
CARDIOVASCULAR DISEASE, COMPLICATIONS
Pathways for remote assessment of common complications after surgery in low-resource settings are essential in improving the safety and resilience of surgical care systems. This mixed-methods study made recommendations for cross-cultural and cross-language adaptation of the WHQ for use in LMICs, and improved its relevance across cultures and for patients with lower levels of health literacy. Conceptual equivalence, and content and construct validity was confirmed across languages using qualitative and translation methods. Unidimensionality, measurement properties, and use of the total WHQ score were seen to be valid within the Rasch framework, although the overall power of fit was low. The telephone pathway was demonstrated to be feasible and highly acceptable. Working with CEI partners, recommendations were made for optimization of telephone follow-up in research and postoperative surveillance programmes. This study provides a large, international, high-quality proof of concept for rapid adaptation and implementation of patient-reported measures in emerging global health arenas such as surgery.The use of mixed methods here added strength and depth. The qualitative data were used primarily to inform cross-cultural adaptation ahead of translation. Although this was based on cognitive theory, data were collected indirectly about patient experience from frontline clinicians involved in wound assessment. The Rasch analysis supplemented this, and allowed patient-level data to enrich and inform final recommendations for adaptation. In a majority of instances, the qualitative and quantitative data were supportive of one another, demonstrating coherence during triangulation. Where conflict arose, qualitative findings were softened and/or caveated (that is, changes were recommended where there was coherence on triangulation, and further exploration recommended where there was conflict between the qualitative and quantitative data).Rasch analysis is an established method for instrument development and cross-cultural refinementExploring complex relationships between items and optimizing the measurement properties using subtesting and adjusting for DIF was not the aim here, but warrants further investigation. It is feasible that the instrument could be simplified, or its diagnostic accuracy could be improved using Rasch by better accounting for differences in the symptomology and health-seeking behaviours of patients with SSI across countries. DIF by country observed for several items here supports methods to ensure balance in randomized trials, such as stratification or minimization of randomization by country.This study has several limitations. Owing to safety and ethical concerns during the SARS-CoV-2 pandemic, cognitive interviewing could not be undertaken directly with patients. Instead, aggregate perspectives of frontline clinicians involved in the care of surgical patients were explored. This meant that the data represented clinicians’ impressions of patients’ responses, and challenges in retrieval and judgement, rather than direct exploration with patients in typical cognitive interviewingThe use of patient-reported outcome measures (PROMs) in low-income settings is complex; many instruments have not yet undergone cross-cultural and cross-language adaptation, and there is uncertainty about the feasibility of remote, digital methods. Although examples exist from established global health fields, such cardiovascular disease, few studies in global surgery have adopted PROMs to date