Responding to Changing Student Demographics in Finland: A Study of Teachers’ Developing Cultural Competence

The aim of this dissertation was to examine the skills and knowledge that pre-service teachers and teachers have and need about working with multilingual and multicultural students from immigrant backgrounds. The specific goals were to identify pre-service teachers’ and practising teachers’ current knowledge and awareness of culturally and linguistically responsive teaching, identify a profile of their strengths and needs, and devise appropriate professional development support and ways to prepare teachers to become equitable culturally responsive practitioners. To investigate these issues, the dissertation reports on six original empirical studies within two groups of teachers: international pre-service teacher education students from over 25 different countries as well as pre-service and practising Finnish teachers. The international pre-service teacher sample consisted of (n = 38, study I; and n = 45, studies II-IV) and the pre-service and practising Finnish teachers sample encompassed (n = 89, study V; and n = 380, study VI). The data used were multi-source including both qualitative (students’ written work from the course including journals, final reflections, pre- and post-definition of key terms, as well as course evaluation and focus group transcripts) and quantitative (multi-item questionnaires with open-ended options), which enhanced the credibility of the findings resulting in the triangulation of data. Cluster analytic procedures, multivariate analysis of variance (MANOVA), and qualitative analyses mostly Constant Comparative Approach were used to understand pre-service teachers’ and practising teachers’ developing cultural understandings. The results revealed that the mainly white / mainstream teacher candidates in teacher education programmes bring limited background experiences, prior socialisation, and skills about diversity. Taking a multicultural education course where identity development was a focus, positively influenced teacher candidates’ knowledge and attitudes toward diversity. The results revealed approaches and strategies that matter most in preparing teachers for culturally responsive teaching, including but not exclusively, small group activities and discussions, critical reflection, and field immersion. This suggests that there are already some tools to address the need for the support needed to teach successfully a diversity of pupils and provide in-service training for those already practising the teaching profession. The results provide insight into aspects of teachers’ knowledge about both the linguistic and cultural needs of their students, as well as what constitutes a repertoire of approaches and strategies to assure students’ academic success. Teachers’ knowledge of diversity can be categorised into sound awareness, average awareness, and low awareness. Knowledge of diversity was important in teachers’ abilities to use students’ language and culture to enhance acquisition of academic content, work effectively with multilingual learners’ parents/guardians, learn about the cultural backgrounds of multilingual learners, link multilingual learners’ prior knowledge and experience to instruction, and modify classroom instruction for multilingual learners. These findings support the development of a competency based model and can be used to frame the studies of pre-service teachers, as well as the professional development of practising teachers in increasingly diverse contexts. The present set of studies take on new significance in the current context of increasing waves of migration to Europe in general and Finland in particular. They suggest that teacher education programmes can equip teachers with the necessary attitudes, skills, and knowledge to enable them work effectively with students from different ethnic and language backgrounds as they enter the teaching profession. The findings also help to refine the tools and approaches to measuring the competencies of teachers teaching in mainstream classrooms and candidates in preparation.Väitöskirjan tavoitteena oli selvittää niitä taitoja ja tietoja, joita opettajilla ja opettajaksi opiskelevilla tulisi olla heidän työskennellessään monikielisten ja -kulttuuristen maahanmuuttajataustaisten oppilaiden kanssa. Erityisenä tavoitteena oli selvittää opettajaksi opiskelevien ja jo opettajan ammatissa toimivien tämänhetkistä tietoisuutta ja tietoa kulttuurillisesti ja kielellisesti vastuullisesta opetuksesta. Tarkoituksena oli tunnistaa vahvuuksia ja heikkouksia sekä suunnitella tarkoituksenmukaisia täydennyskoulutuksen malleja ja sellaisia tuen muotoja, joiden avulla opettajat voisivat kehittyä oikeudenmukaisiksi ja kulttuurisesti vastuullisiksi ammattilaisiksi. Näitä kysymyksiä tarkasteltiin väitöskirjan kuudessa empiirisessä alkuperäistutkimuksessa, jotka kohdistuivat kahteen eri ryhmään: 25 eri maata edustanee-seen kansainvälisten opettajaopiskelijoiden ryhmään (n = 38 osatutkimuksessa I; n = 45 osatutkimuksissa II–V) sekä suomalaisiin opettajaksi opiskeleviin ja opettajan ammatissa toimiviin (n = 89 osatutkimuksessa V; n = 380 osatutkimuksessa VI). Tutkimusaineisto koostui erityyppisistä lähteistä sisältäen laadullisia aineistoja (opiskelijoiden kirjoitelmat, kuten oppimispäiväkirjat, kurssin loppupohdinnat, keskeisten käsitteiden määrittelyt alku- ja loppumittauksissa, kurssiarvioinnit sekä valikoidun osajoukon keskustelut) sekä määrällisiä aineistoja (monista kysymyksistä koostuneet kyselylomakkeet, joissa oli myös avoimia kysymyksiä). Monimetodinen lähestymistapa ja eri aineistojen vertailu lisäsivät tutkimuksen löydösten luotettavuutta. Opettajaopiskelijoiden ja opettajien kulttuurisen ymmärryksen tutkimiseksi aineistoa analysoitiin klusterianalyysillä ja monimuuttujaisella varianssianalyysillä sekä laadullisilla menetelmillä (esim. Constant Comparative Approach). Tulokset osoittivat, että opettajakoulutuksen pääosin kantasuomalaisella opettaja-opiskelijajoukolla on vain vähän kokemusta, aikaisempaa osallistumistaustaa tai tietotaitoa kulttuurisesta monimuotoisuudesta. Monikulttuurisuutta ja identiteettiä painottavaan opintojaksoon osallistuminen vaikutti positiivisesti koulutukseen osallistuneiden tietämykseen ja asenteisiin, jotka liittyivät kulttuuriseen moninaisuuteen ja erilaisuuteen. Tuloksissa tuodaan esiin sellaisia näkökulmia ja strategioita, joilla on merkitystä valmennettaessa opiskelijoita kulttuurisesti vastuulliseen opettajuuteen. Tällaisia menetelmiä ovat mm. pienryhmäharjoitukset ja -keskustelut, kriittiset pohdinnat ja syvempi tutustuminen opetuskentän tilanteeseen. Näitä menetelmiä ja työkaluja, joiden avulla voidaan vastata kulttuurisesta monimuotoisuudesta kumpuavaan tarpeeseen, olisi siis saatavilla myös jo opettajan ammatissa toimivien käyttöön. Tulokset lisäävät ymmärrystä siitä, millaista tietoa opettajilla on oppilaiden erilasista kielellisistä ja kulttuurisista tarpeista sekä niistä lähestymistavoista ja strategioista, joita oppilaat tarvitsevat menestyäkseen koulussa. Opettajien tietämys kulttuurisesta moninaisuudesta voidaan jakaa kolmeen luokkaan: hyvä tietämys, keskinkertainen tietämys ja heikko tietämys. Tämä tietämys vaikuttaa merkittävästi opettajien valmiuteen hyödyntää oppilaiden kieltä ja kulttuuria akateemisten taitojen rakentamisen apuna sekä siihen, miten he pystyvät työskentelemään tehokkaasti maahanmuuttajataustaisten vanhempien ja huoltajien kanssa. Lisäksi se vaikuttaa opettajien valmiuksiin oppia tuntemaan maahanmuuttajataustaisten oppilaiden kulttuurisia taustoja, yhdistää opetus oppijan aikaisempaan osaamiseen ja kokemuksiin sekä muuntaa opetusta vastaamaan monikielisten oppijoiden tarpeita. Tutkimustulokset vahvistavat käsitystä osaamiseen perustuvista malleista, ja niitä voidaan hyödyntää opettaankoulutuksen apuna sekä erilaisissa ympäristöissä toimivien opettajien kehityksen tukena. Nämä osatutkimukset saavat uuden merkityksen nykyisessä tilanteessa, jossa muuttoliike Eurooppaan yleensä ja Suomeen erityisesti on lisääntynyt. Tulokset antavat viitteitä siitä, että opettajankoulutus voi tarjota opettajaksi opiskeleville sellaisia suhtautumistapoja, taitoja ja tietämystä, jotka auttavat heitä tulevassa opettajan ammatissaan työskentelemään tehokkaasti erilaisista kieli- ja kulttuuritaustoista tulevien oppilaiden kanssa. Tulokset auttavat myös kehittämään sellaisia työkaluja ja menettelytapoja, joiden avulla voidaan mitata sekä pääosin kantasuomalaisista oppilaista koostuvien luokkien opettajien että vasta opettajaksi opiskelevien osaamista.Siirretty Doriast

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Monolingual practices confronting multilingual realities. Finnish teachers’ perceptions of linguistic diversity

This study examined Finnish teachers' (N = 820) beliefs related to multilingualism and teaching multilingual Finnish language learners. Teachers' beliefs were mainly positive. However, teachers did not always consider home languages as learning resources. There were three categories of multilingual ideologies: advocacy for, allowance and denial of multilingualism in the classroom. Factors influencing the teachers’ beliefs were experience in teaching migrants, teaching area, training in linguistically responsive teaching and language awareness. The results indicate a need for professional development for all teachers to promote a move away from maintaining monolingualism to advocating for multilingualism to better reflect the realities of the classrooms

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study

Background: Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid. Methods: Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals. Results: A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53–163.57, p = 0.021). Conclusions: With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P&lt;0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P&lt;0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially