Pediatric Regional Anesthesia Survey in South Africa ( <scp>PRASSA</scp> ): A Descriptive, Cross‐Sectional Survey of Knowledge, Attitudes, and Practices Among South African Anesthetists

Abstract

Pediatric regional anesthesia (PRA) has evolved rapidly over the past two decades, largely driven by the widespread adoption of ultrasound guidance and the accumulation of high-quality safety data. Large prospective registries, including those from the French-Language Society of Pediatric Anesthesiologists (ADARPEF) and the Pediatric Regional Anesthesia Network, have demonstrated that when PRA is performed by appropriately trained clinicians with suitable equipment, the benefits outweigh the risks [1]. Effective perioperative pain management in children is essential, as inadequately treated pain may have both immediate and long-term consequences. Despite this, the uptake of PRA in low- and middle-income countries (LMICs) remains inconsistent [2]. In South Africa, PRA is included within general training but is not assessed as a distinct competency or supported by mandated procedural requirements, resulting in variable exposure dependent on institutional resources and expertise. Pediatric anesthesia is largely delivered by generalist anesthetists across public and private sectors, and little is known about clinicians' knowledge, attitudes, and practices regarding PRA. Understanding these factors is critical to informing targeted, context-appropriate strategies to advance PRA and improve perioperative care for children. A descriptive, cross-sectional survey was conducted using an online questionnaire distributed via the South African Society of Anaesthesiologists (SASA) research database between April and May 2024. The survey was developed following a literature review and piloted among anesthetists of varying seniority, including pediatric anesthesia specialists. It comprised three sections: demographic and practice characteristics; attitudes toward PRA assessed using eight 4-point Likert-scale statements; and knowledge assessed through 10 true–false statements with an “unsure” option to reduce guessing. An a priori threshold of ≥ 6 correct responses (≥ 60%) was used to indicate adequate knowledge, selected pragmatically for descriptive comparison in the absence of a validated benchmark. Knowledge items were informed by international PRA guidelines. Additionally, perceived barriers and facilitators were assessed using a predefined select-all-that-apply list, with an optional free-text field for elaboration. Frequencies were reported for predefined items, while free-text responses were used descriptively and were not subjected to formal thematic analysis. Participation was voluntary and anonymous, with electronic informed consent required prior to survey completion. Data were collected using REDCap [3] and analyzed using descriptive statistics and inferential methods. Only fully completed questionnaires were included in the final analysis. No imputation of missing data was performed. An overall attitude score was calculated, internal consistency assessed using Cronbach's alpha, and factors associated with attitudes explored using regression modeling. Ethical approval was obtained from the Sefako Makgatho University Research Ethics Committee (SMUREC Reference number: SMUREC/M/139/2023:PG). Of 727 eligible SASA members, 180 initiated the survey (response rate 24.8%), and 142 completed questionnaires were included in the analysis (completion rate 78.9%). Over one-third of respondents had more than 15 years of anesthetic practice, and just over one-quarter were trainees. Respondents were distributed across public, private, and mixed practice settings. While more than half reported some form of additional regional anesthesia training, formal postgraduate qualifications or fellowships were uncommon. Among respondents with exposure to pediatric anesthesia, fewer than 40% reported performing PRA often or routinely, and continuous catheter techniques were rarely used. Most respondents believed they were able to perform PRA safely, although failed or abandoned blocks and vascular puncture were commonly reported complications, with a minority indicating subsequent changes in practice. The principal perceived barriers to PRA were lack of experience and training, whereas the most frequently cited facilitator was surgeon support. There was not a significant difference in equipment-related barriers between the private and public sectors. Free-text responses highlighted time pressure, equipment availability, consent challenges, and the importance of teamwork and mentorship. Attitudes toward PRA were generally positive, with strong agreement regarding its importance for pediatric pain management and its potential benefits in LMICs (Figure 1). However, clinicians with longer duration of practice demonstrated less favorable attitudes, while all trainees indicated willingness to perform more PRA if adequate resources and opportunities were available. Knowledge gaps were evident, with fewer than 40% of respondents achieving an adequate knowledge score, particularly among trainees and non-specialists. This study has several limitations. The opt-in survey design and modest response rate introduce potential selection bias, with respondents possibly more favorably disposed towards PRA than non-respondents. The knowledge threshold was pragmatically defined and not externally validated. Equipment availability was not systematically characterized by type and pediatric-specific consumables were more often cited as equipment-related barriers in free-text responses rather than ultrasound availability. This is consistent with prior South African data [4]. This national survey suggests that PRA remains underutilized in South Africa despite broadly positive attitudes and perceived safety among anesthetists. The identified gaps in knowledge, training, and experience—alongside system-level and cultural barriers—mirror challenges reported in other LMIC settings. Importantly, the strong enthusiasm among trainees and the recognition of surgeon engagement as a key facilitator point to actionable levers for change. Given that pediatric anesthesia is not a formally recognized subspecialty in most African contexts, scalable solutions that support generalist anesthetists are essential. There is a clear need for focused educational initiatives to strengthen knowledge and technical skills in regional anesthesia. Evidence supports the value of non-fellowship, competency-based training pathways, with consensus recommendations favoring a standardized curriculum to complement existing guidelines [5]. Structured regional anesthesia training programs implemented in resource-constrained settings have demonstrated favorable educational and clinical outcomes [6], suggesting that similar models may be feasible and effective within the South African public sector. Short-course, high-yield training models focused on a limited number of versatile high value “Plan A” blocks (axillary brachial plexus, femoral, popliteal sciatic, rectus sheath, lateral quadratus lumborum, caudal and dorsal penile blocks) [7], combined with mentorship and interdisciplinary engagement, may represent a pragmatic approach. Such initiatives could also address persistent misconceptions regarding time inefficiency and safety. This study provides the first national snapshot of PRA-related knowledge, attitudes, and practices in South Africa. These findings may serve as a needs assessment to inform future educational interventions and support broader efforts to strengthen pediatric perioperative care in resource-constrained settings [8, 9]. Use of Artificial Intelligence Generated Content: Artificial intelligence–assisted tools were used to support language refinement, structural editing, and clarity of presentation of the manuscript. The AI tool did not generate original data, perform data analysis, or influence study design, interpretation of results, or conclusions. All content was reviewed, edited, and approved by the authors, who take full responsibility for the integrity and accuracy of the work. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are openly available in Figshare at https://doi.org/10.6084/m9.figshare.31187854.