This section combines information from the above-mentioned sources. The results illustrate how some of the participants have moved the NSOAP process forward in their countries and the challenges they face in trying to maintain momentum, and applyknowledge and skills from the series in practical terms.

With the exception of one Level 3 survey respondent, participants enrolled in the series to acquire new knowledge and grow in their professional life. In line with Figure 1, they indicated that applying knowledge from the series was (very) important for their professional lives. Participants applied knowledge and skills differently. The changes identified and application of knowledge in  the workplace as a result of the learning series can be summarized in six  categories, as illustrated below:

• Improvement of data quality and use: As a result of the series, participants have improved the quality of data used in their workplace using recommended approaches from the learning events, as well as data collection and analysis processes.

At my local hospital, we create a multidisciplinary working group between Neonatology and Pediatrics Surgery to improve our quality indicators.

• Emerging NSOAP processes: Five cases were identified where (country) NSOAP processes were, or planned to be, strengthened after the series.

The series will inform the foundation to start the design of the NSOAP for Uganda.

These series have enabled me to take the NSOAP process forward in Nigeria though only through advocacy via social media.

I initially have engaged our country Somaliland, the Ministry of Health Development, and I am still committed to work on it.

• Transfer of knowledge and skills to other professionals: Participants have shared some of the knowledge from the series with colleagues at work (mostly informally) or with their professional networks.

I'm working in a project at the JDN WMA to spread basic concepts of global surgery in Latin America young residents doctors.

I am part of a student organization called Pakistan Global Surgery Student Association, and intend on delivering talks of similar nature to the members of this organization.

• Broaden participants’ perspectives on the topic: Participants have increased their understanding of the topic and now have a different perception of the subject matter. One even indicated their plans to pursue a professional path related to the topic in question.

I have a renewed perspective on seeing my future career as a surgeon and global health shaper. I am more open and excited to take part in global surgery projects in the future.

The series informed me of the need for training more surgeons and awareness promotion of gap in surgical accessibility.

• Research activities: In a few cases, information from the NSOAP series helped inform research activities.

The NSOAP has been greatly useful in my research development and getting to understand more about security and peace.

• Incorporation of knowledge in academic lectures: Some participants indicated their willingness to incorporate the knowledge from the series, e.g., basic concepts, into their lectures at medical school. However, for this category, all examples suggest they have not yet done so, but plan on doing it in the future. 

I will teach the students.

I will extend the lessons to my university.

The sources of information also suggest that although not all participants have applied knowledge and skills from the series, they are interested in being involved in NSOAP processes in their countries.

I would want to be more involved in the NSOAP process in my country.

Additionally, participants pointed out the challenges that prevented them from applying knowledge and skills from the series as they would like. Box 1 illustrates an example of barriers to applying knowledge and skills from a participant in Kenya. Challenges encountered by participants include:

• Bureaucracy and competing priorities: As NSOAP requires a national effort, not all participants have found the opportunity to engage with national actors who could foster the process, or they have discovered that surgical, obstetric and anaesthesia (SOA) services are not a priority for national stakeholders.

It's very difficult for authorities to prioritise this right now, even though its importance has been stressed several times.

The health system in my country varies as per different states so a national programme won't be possible.

Competing interests/other projects take up time.

• Opportunity to apply knowledge in current work position: Some of the participants enrolled in the series to increase their technical knowledge of the topic, but their area of expertise/work does not allow them to apply the knowledge learned.

As a young medical doctor working in a hospital I cannot establish the NSOAP process but I have enough basic information to share with health professionals that would help.

• Lack of information on the NSOAP process: One example indicated that there was limited information on the progress of the NSOAP process in their country.

There was a presentation on the NSOAP process but it was fairly opaque and limited to only two elite institutions.

Suggestions from participants to overcome these challenges and future considerations include broadening language accessibility of the NSOAP series and materials (e.g., manual), increased exchange between participants, offering courses on fundamentals of global surgery, and organizing national workshops.

This Impact Story showcases the importance and opportunity to foster NSOAP processes, especially in low-and-middle-income countries. While some participants have used or applied the knowledge from the series, others have faced barriers to using/applying the new knowledge.

The examples reviewed suggest that many of the participants who were able to apply the knowledge were involved in relevant-to-the-topic initiatives, including NSOAP processes. Participants have applied knowledge and skills differently, from increased awareness to transfer of knowledge in academic settings (i.e., medical school) and NSOAP processes in their countries. On the other hand, most of the inhibiting factors are related to structures and hierarchies at the national or local level which make it more difficult for participants to take the initiative to lead these processes. As mentioned by some participants, reaching out to relevant stakeholders (e.g., ministries of health) is critical to promote NSOAP processes, especially in low-and-middle-income countries.