Factors Affecting the Implementation of Enhanced Recovery After Surgery (ERAS) Protocols in Pediatric Surgery Practice in Sudan – 2026: A Mixed Methods Study
Author Affiliations
- University of Khartoum, Faculty of Medicine, Khartoum, Sudan.
- The Operating Room Global (TORG).
- Department of Surgery, Debre Markos University, Debre Markos, Ethiopia.
Corresponding author: Dr. Hani E. Bilal · [email protected]
Abstract
Background: Enhanced Recovery After Surgery (ERAS) is an evidence-based perioperative care pathway designed to reduce surgical stress, complications, and hospital stay. However, implementation in pediatric surgery remains limited in low- and middle-income countries, including Sudan.
Objective: To assess factors affecting ERAS implementation in pediatric surgical practice in Sudan, focusing on knowledge, perceptions, barriers, and facilitators.
Methods: A convergent mixed-methods cross-sectional study was conducted among pediatric surgery stakeholders in Sudan. Quantitative data were collected through structured questionnaires and analyzed using descriptive and inferential statistics. Qualitative data from focus group discussions and key informant interviews underwent thematic analysis, with findings integrated through triangulation.
Results: Among 72 participants, 48.6% demonstrated good ERAS knowledge, 37.5% moderate knowledge, and 13.9% poor knowledge, while 66.7% reported positive perceptions. Major barriers included absent ERAS protocols and national guidelines, limited pediatric-specific knowledge, inadequate monitoring, poor multidisciplinary coordination, and financial constraints. Qualitative findings highlighted willingness to adopt ERAS despite institutional, workforce, infrastructure, training, and policy limitations.
Conclusion: Despite positive perceptions and moderate knowledge, pediatric ERAS implementation in Sudan faces significant institutional and systemic barriers. National guidelines, multidisciplinary collaboration, workforce training, and institutional support are essential for sustainable implementation.
Keywords: Enhanced Recovery After Surgery (ERAS); Pediatric Surgery; Implementation; Knowledge; Barriers; Sudan.
Study Highlights
| ERAS knowledge category | Participants | Percentage |
|---|---|---|
| Good | 35 | 48.6% |
| Moderate | 27 | 37.5% |
| Poor | 10 | 13.9% |
| Implementation indicator | Finding |
|---|---|
| Positive perceptions of ERAS | 66.7% |
| Formal prior ERAS training | 23.6% |
| Documented ERAS protocol reported | 12.5% |
| No documented ERAS protocol reported | 68.1% |
Data from the published study (n = 72). See the PDF for full analyses, tables, figures and interpretation.
Barriers to Implementation
The highest-ranked perceived barriers were institutional and system-level factors rather than opposition from patients or families.
| Rank | Barrier | Mean (SD) |
|---|---|---|
| 1 | Absence of documented ERAS protocols | 4.01 (1.13) |
| 2 | Limited pediatric-specific ERAS evidence knowledge | 3.81 (1.11) |
| 3 | Absence of national guidelines | 3.79 (1.29) |
| 4 | Lack of audit and monitoring systems | 3.78 (1.45) |
| 5 | Insufficient multidisciplinary coordination | 3.71 (1.27) |
| 6 | Financial limitations | 3.69 (1.39) |
Qualitative themes
Willingness without structure: Clinicians expressed interest in ERAS, but lacked formal pathways and coordinated implementation structures.
Workforce and resource constraints: Interviewees described infrastructure, staffing, specialist service and equipment limitations.
Training and advocacy: Participants recommended multidisciplinary training, institutional leadership, national guidance, audit systems and engagement with caregivers and policymakers.
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Declarations & Ethics
Ethical approval: TORG Institutional Review Board (TORG-IRB/2026/032801; 4 June 2026) and Sudan National Research Ethics Committee (RA017082026).
Informed consent: Obtained from participants, including electronic agreement for online surveys and written or recorded verbal consent for focus groups and interviews, as described in the article.
Conflicts of interest: None declared.
Funding: No external funding received.
Data availability: Study datasets are available from the corresponding author on reasonable request.
Author contributions: Hani E. Bilal: conceptualisation, methodology, investigation, data collection, formal analysis, interpretation and original draft. Megbar Dessalegn: supervision, methodology, interpretation, review and editing. Both authors approved the final manuscript.
Acknowledgements: The authors acknowledge The Operating Room Global Research Fellowship Programme, mentorship from Dr. Megbar Dessalegn and guidance from Dr. Myada Ibrahim.
Artificial intelligence declaration: The published article reports the use of generative AI for language refinement, grammatical correction, sentence clarity and organisation of written content. The author states that the scientific work and final intellectual content were verified by the author.
Publication Information
Accepted: 14 October 2026
Published online: 25 October 2026
ISSN 3105-3262
Volume 2, Issue 4 (December 2026), pp. 77–89
Creative Commons Attribution 4.0
Read the Full Article
The full manuscript, detailed methodology, statistical analyses, figures, discussion, limitations, recommendations and references are available in the published PDF.