Non-technical skills training for Nigerian interprofessional surgical teams: a cross-sectional survey.

INTRODUCTION: Non-technical skills (NTS) including communication, teamwork, leadership, situational awareness, and decision making, are essential for enhancing surgical safety. Often perceived as tangential soft skills, NTS are many times not included in formal medical education curricula or continuing medical professional development. We aimed to explore exposure of interprofessional teams in North-Central Nigeria to NTS and ascertain perceived facilitators and barriers to interprofessional training in these skills to enhance surgical safety and inform design of a relevant contextualized curriculum. METHODS: Six health facilities characterised by high surgical volumes in Nigeria's North-Central geopolitical zone were purposively identified. Federal, state, and private university teaching hospitals, non-teaching public and private hospitals, and a not-for-profit health facility were included. A nineteen-item, web-based, cross-sectional survey was distributed to 71 surgical providers, operating room nurses, and anaesthesia providers by snowball sampling through interprofessional surgical team leads from August to November 2021. Data were analysed using Fisher's exact test, proportions, and constant comparative methods for free text responses. RESULTS: Respondents included 17 anaesthesia providers, 21 perioperative nurses, and 29 surgeons and surgical trainees, with a 95.7% survey completion rate. Over 96% had never heard of any NTS for surgery framework useful for variable resource contexts and only 8% had ever received any form of NTS training. Interprofessional teams identified communication and teamwork as the most deficient personal skills (38, 57%), and as the most needed for surgical team improvement (45, 67%). There was a very high demand for NTS training by all surgical team members (64, 96%). The main motivations for training were expectations of resultant improved patient safety and improved interprofessional team dynamics. Week-long, hybrid training courses (with combined in-person and online components) were the preferred format for delivery of NTS education. Factors that would facilitate attendance included a desire for patient safety and self-improvement, while barriers to attendance were conflicts of time, and training costs. CONCLUSIONS: Interprofessional surgical teams in the Nigerian context have a high degree of interest in NTS training, and believe it can improve team dynamics, personal performance, and ultimately patient safety. Implementation of NTS training programs should emphasize interprofessional communication and teamworking.

Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

The Implementation of Simulation-Based Learning for Training Undergraduate Medical Students in Essential Surgical Care Across Sub-Saharan Africa: a Scoping Review.

Much surgery in sub-Saharan Africa is provided by non-specialists who lack postgraduate surgical training. These can benefit from simulation-based learning (SBL) for essential surgery. Whilst SBL in high-income contexts, and for training surgical specialists, has been explored, SBL for surgical training during undergraduate medical education needs to be better defined. From 26 studies, we identify gaps in application of simulation to African undergraduate surgical education, including lack of published SBL for most (65%) World Bank-defined essential operations. Most SBL is recent (2017-2021), unsustained, occurs in Eastern Africa (78%), and can be enriched by improving content, participant spread, and collaborations.

The Impact of Colonialism on Surgical Training Structures in Africa Part 1: Contextualizing the Past, Present, and Future.

Since the first African country attained independence from colonial rule, surgical training on the continent has evolved along 3 principal models. The first is a colonial, local master-apprentice model, the second is a purely local training model, and the third is a collegiate intercountry model. The 3 models exist currently and there are varied perceptions of their relative merits in training competent neurosurgeons. We reviewed the historical development of training and in an accompanying study, seek to describe the complex array of surgical training pathways and explore the neocolonial underpinnings of how these various models of training impact today the development of surgical capacity in Africa. In addition, we sought to better understand how some training systems may contribute to the widely recognized "brain drain" of surgeons from the African continent to high income countries in Europe and North America. To date, there are no published studies evaluating the impact of surgical training systems on skilled workforce emigration out of Africa. This review aims to discover potentially addressable sources of improving healthcare and training equity in this region.

Health system's availability and readiness of health facilities for chronic non-communicable diseases: Evidence from the Ethiopian national surveys.

INTRODUCTION: Non-communicable diseases (NCDs) currently cause more deaths than all other causes of deaths. Cardiovascular disease, diabetes, cancer, and chronic respiratory diseases-threaten the health and economies of individuals and populations worldwide. This study aimed to assess the availability and readiness of health facilities for chronic non-communicable diseases (NCDs) and describe the changes of service availability for common NCDs in Ethiopia. Methods We used data from the 2014 Ethiopia Service Provision Assessment Plus (ESPA +) and 2016 and 2018 Service Availability and Readiness Assessment (SARA) surveys, which were cross-sectional health facility-based studies. A total of 873 health facilities in 2014, 547 in 2016, 632 in 2018 were included in the analysis. (ESPA+) and SARA surveys are conducted as a census or a nationally/sub-nationally representative sample of health facilities. Proportion of facilities that offered the service for diabetes, cardiovascular disease, chronic respiratory disease, cancer diseases, mental illness, and chronic renal diseases was calculated to measure health service availability. The health facility service readiness was measured using the mean availably of tracer items that are required to offer the service. Thus, 13 tracer items for diabetes disease, 12 for cardiovascular disease, 11 for chronic respiratory disease and 11 cervical cancer services were used. RESULTS: The services available for diagnosis and management did not show improvement between 2014, 2016 and 2018 for diabetes (59%, 22% and 36%); for cardiovascular diseases (73%, 41% and 49%); chronic respiratory diseases (76%, 45% and 53%). Similarly, at the national level, the mean availability of tracer items between 2014, 2016 and 2018 for diabetes (37%, 53% and 48%); cardiovascular diseases (36%, 41% and 42%); chronic respiratory diseases (26%, 27% and 27%); and cancer diseases (6%, 72% and 51%). However, in 2014 survey year, the mean availability of tracer items was 7% each for mental illness and chronic renal diseases, respectively. CONCLUSIONS: The majority of the health facilities have low and gradual decrement in the availability to provide NCDs services in Ethiopia. There is a need to increase NCD service availability and readiness at primary hospitals and health centers, and private and rural health facilities where majority of the population need the services.

The Impact of Colonialism on Surgical Training Structures In Africa Part 2: Surveying Current and Past Trainees.

BACKGROUND: As a result of gradual independence from colonial rule over the course of the past century, Africa has developed and evolved 3 primary surgical training structures: an extracontinental colonial model, an intracontinental college-based model, and several smaller national or local models. There is consistent evidence of international brain drain of surgical trainees and an unequal continental distribution of surgeons; however there has not, to date, been an evaluation of the impact colonialism on the evolution of surgical training on the continent. This study aims to identify the etiologies and consequences of this segmentation of surgical training in Africa. METHODS: This is a cross-sectional survey of the experience and perspectives of surgical training by current African trainees and graduates. RESULTS: A surgeon's region of residence was found to have a statistically significant positive association with that of a surgeon's training structure (P <0.001). A surgeon's professional college or structure of residency has a significantly positive association with desire to complete subspecialty training (P = 0.008). College and structure of residency also are statistically significantly associated with successful completion of subspecialty training (P < 0.001). CONCLUSIONS: These findings provide evidence to support the concept that the segmentation of surgical training structures in Africa, which is the direct result of prior colonization, has affected the distribution of trainees and specialists across the continent and the globe. This maldistribution of African surgical trainees directly impacts patient care, as the surgeon-patient ratios in many African countries are insufficient. These inequities should be acknowledged addressed and rectified to ensure that patients in Africa receive timely and appropriate surgical care.

Nonmalignant tracheal stenosis: presentation, management and outcome in limited resources setting.

BACKGROUND: Nonmalignant tracheal stenosis is a potentially life threatening conditions that develops as fibrotic healing from intubation, tracheostomy, caustic injury or chronic infection processes like tuberculosis. This is a report of our experience of its management with tracheostomy, rigid bronchoscopic dilation and surgery. METHODS: Retrospective study design was used. 60 patients treated over five years period were included. RESULTS: Mean age was 26.9 ± 10.0 with a range of 10-55 years. Majority (56 patients (93.3%)) had previous intubation as a cause for tracheal stenosis. Mean duration of intubation was 13.8 days (range from 2 to 27 days). All patients were evaluated with neck and chest CT (Computed Tomography) scan. Majority of the stenosis was in the upper third trachea - 81.7%. Mean internal diameter of narrowest part was 5.5 ± 2.5 mm, and mean length of stenosed segment was 16.9 ± 8 mm. Tracheal resection and end to end anastomosis (REEA) was the most common initial modality of treatment followed by bronchoscopic dilation (BD) and primary tracheostomy (PT). The narrowest internal diameter of the tracheal stenosis (TS) for each initial treatment category group was 4.4 ± 4.3 mm, 5.1 ± 1.9 mm and 6.7 ± 1.6 mm for PT, tracheal REEA and BD respectively, and the mean difference achieved statistical significance, F (10,49) = 2.25, p = 0.03. Surgery resulted in better outcome than bronchoscopic dilation (89.1% vs. 75.0%). DISCUSSION AND CONCLUSION: Nonmalignant tracheal stenosis mostly develops after previous prolonged intubation. Surgical resection and anastomosis offers the best outcome.

Scalability and Sustainability of a Surgical Infection Prevention Program in Low-Income Environments.

Importance: Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low-resource settings. Clean Cut, a 6-month quality improvement program developed by the global nonprofit organization Lifebox, has demonstrated improvements in postoperative infectious complications. However, the pilot program required intense external programmatic and resource support. Objective: To examine the improvement in adherence to infection prevention and control standards and rates of postoperative infections in hospitals in the Clean Cut program after implementation strategies were updated and program execution was refined. Design, Setting, and Participants: This cohort study evaluated and refined the Clean Cut implementation strategy to enhance scalability based on a qualitative study of its pilot phase, including formalizing programmatic and educational materials, building an automated data entry and analysis platform, and reorganizing hospital-based team composition. Clean Cut was introduced from January 1, 2019, to February 28, 2022, in 7 Ethiopian hospitals that had not previously participated in the program. Prospective data initiated on arrival in the operating room were collected, and patients were followed up through hospital discharge and with 30-day follow-up telephone calls. Exposure: Implementation of the refined Clean Cut program. Main Outcomes and Measures: The primary outcome was surgical site infection (SSI); secondary outcomes were adherence to 6 infection prevention standards, mortality, hospital length of stay, and other infectious complications. Results: A total of 3364 patients (mean [SD] age, 26.5 [38.0] years; 2196 [65.3%] female) from 7 Ethiopian hospitals were studied (1575 at baseline and 1789 after intervention). After controlling for confounders, the relative risk of SSIs was reduced by 34.0% after program implementation (relative risk, 0.66; 95% CI, 0.54-0.81; P < .001). Appropriate Surgical Safety Checklist use increased from 16.3% to 43.0% (P < .001), surgeon hand and patient skin antisepsis improved from 46.0% to 66.0% (P < .001), and timely antibiotic administration improved from 17.8% to 39.0% (P < .001). Surgical instrument (38.7% vs 10.2%), linen sterility (35.5% vs 12.8%), and gauze counting (89.2% vs 82.5%; P < .001 for all comparisons) also improved significantly. Conclusions and Relevance: A modified implementation strategy for the Clean Cut program focusing on reduced external resource and programmatic input from Lifebox, structured education and training materials, and wider hospital engagement resulted in outcomes that matched our pilot study, with improved adherence to recognized infection prevention standards resulting in a reduction in SSIs. The demonstration of scalability reinforces the value of this SSI prevention program.

The practice of breast self-examination and associated factors among female healthcare professionals working in selected hospitals in Kigali, Rwanda: a cross sectional study.

BACKGROUND: Breast self-examination (BSE) is considered one of the main screening methods in detecting earlier stages of breast cancer. It is a useful technique if practiced every month by women above 20 years considering that breast cancer among women globally contributed to 685,000 deaths in 2020. However, the practice of breast self-examination among healthcare professionals is low in many developing countries and it is not well known in Rwanda. Therefore, this research was intended to measure the level of breast self-examination practice and its associated factors among female healthcare professionals working in selected hospitals in Kigali, Rwanda. METHODS: A cross-sectional study was conducted among 221 randomly selected female healthcare professionals in four district hospitals in Kigali, Rwanda. A self-administered structured questionnaire was used as data collection instrument. The predictor variables were socio-demographic and obstetrics variables, knowledge on breast cancer and breast self-examination as well as attitude towards breast cancer and breast self-examination. Sample statistics such as frequencies, proportions and mean were used to recapitulate the findings in univariate analysis. Multiple logistic regression analysis was employed to identify statistically significant variables that predict breast self-examination practice. Adjusted odds ratio with 95% confidence level were reported. P-value < 0.05 was used to declare statistical significance. RESULTS: Breast self-examination was practiced by 43.5% of female healthcare professionals. This prevalence is low compared to other studies. Attitude towards breast self-examination and breast cancer was the only predictor variable that was significantly associated with breast self-examination practice [AOR = 1.032; 95% CI (1.001, 1.065), p-value = 0.042]. However, number of pregnancy and number of children were not significantly associated with BSE practice in the multi-variate analysis. In addition, there was a positive linear link between knowledge and attitude, with a correlation coefficient (r) of 0.186 (p = 0.005). CONCLUSIONS: The breast self-examination practice among healthcare professionals was found to be low. Attitude towards breast cancer and breast self-examination was positively associated with BSE practice. Moreover, attitude and knowledge were positively correlated. This suggests the need for continuous medical education on breast self-examination and breast cancer to increase the knowledge & BSE practice level of female healthcare professionals.

Barriers to equitable access to quality trauma care in Rwanda: a qualitative study.

OBJECTIVES: Using the 'Four Delay' framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients', caregivers' and community leaders' perspectives. DESIGN: A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically. SETTING: This qualitative study was conducted in Rwanda's rural Burera District, located in the Northern Province, and in Kigali City, the country's urban capital, to capture both the rural and urban population's experiences of being injured. PARTICIPANTS: Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders. RESULTS: Multiple barriers were identified cutting across all levels of the 'Four Delays' framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients. CONCLUSIONS: Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation.

Operative Case Volumes and Variation for General Surgery Training in East, Central, and Southern Africa.

BACKGROUND: Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries. METHODS: Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored. RESULTS: One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level. CONCLUSIONS: Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference.

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

Exploring Laparoscopic Surgery Training Opportunities in the College of Surgeons of East, Central, and Southern Africa region.

OBJECTIVE: The resource-limited environment in Sub-Saharan countries, with a lack of expert trainers, impedes the progress of laparoscopic training. This study aimed to identify the opportunities and limitations of laparoscopic surgery training in the College of Surgeons of East, Central, and Southern Africa (COSECSA) countries. DESIGN AND SETTING: A multicountry online survey was conducted from January 2021 to October 2021 in COSECSA-accredited training hospitals within 16 countries. Available resources and challenges faced in order to set up well-structured laparoscopic training programs were explored. RESULTS: Ninety-four surgeons answered the questionnaire. The average resources reported per hospital were 3 trained laparoscopic surgeons, 2 laparoscopic towers, and 2 sets of laparoscopic instruments. The training of the majority of these surgeons has been in local institutions (53%), a further 37% within African countries and only 10% outside Africa. Approximately 45% of them declared that laparoscopic modules were planned within the University Curricula, while only 18% of surgeons recognized that laparoscopic modules are only planned within the COSECSA program. About 57% of participants reported that at the end of residency training, graduating surgeons were not able to perform basic laparoscopic procedures. The quoted barriers included: limited laparoscopic equipment, absence of simulation lab, lack of qualified trainers, lack of training programs and time for teaching by skilled doctors, and lack of institutional support. CONCLUSIONS: The well-structured set up of laparoscopic training programs in the COSECSA region is hindered due to the lack of qualified personnel and insufficient resources for the acquisition of equipment and simulation laboratories. Ongoing efforts to set up laparoscopic programs through the development of adaptive curricula, innovative strategies for reduction of equipment cost and adequate training of surgeons are crucial for patient safety and the development of laparoscopy.

National Surgical Healthcare Policy Development and Implementation: Where do We Stand in Africa?

BACKGROUND: National surgical policies have been increasingly adopted by African countries over the past decade. This report is intended to provide an overview of the current state of adoption of national surgical healthcare policies in Africa, and to draw a variety of lessons from representative surgical plans in order to support transnational learning. METHODS: Through a desk review of available African national surgical healthcare plans and written contributions from a committee comprising six African surgical policy development experts, a few key lessons from five healthcare plans were outlined and iteratively reviewed. RESULTS: The current state of national surgical healthcare policies across Africa was visually mapped, and lessons from a few compelling examples are highlighted. These include the power of initiative from Senegal; regional leadership from Zambia; contextualization, and renewal of commitment from Ethiopia; multidisciplinary focus and creation of multiple implementation entry points from Nigeria; partnerships and involvement of multiple stakeholders from Rwanda; and the challenge of surgical policy financing from Tanzania. The availability of global expertise, the power of global partnerships, and the critical role of health ministries and Ministers of Health in planning and implementation have also been highlighted. CONCLUSIONS: Strategic planning for surgical healthcare improvement is at various stages across the continent, with potential for countries to learn from one another. Convenings of stakeholders and Ministers of Health from countries at various stages of strategic surgical plan development, execution, and evaluation can enhance African surgical policy development through the exchange of ideas, lessons, and experiences.

Developing a Surgical Simulation Curriculum for the Rwandan Context.

OBJECTIVE: We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda. DESIGN: This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students. SETTING: University of Global Health Equity, a new medical school located in Butaro, Rwanda. PARTICIPANTS: Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship. RESULTS: The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options. CONCLUSIONS: Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students' knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda.

BACKGROUND: An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience. METHODS: An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners' experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys. RESULTS: Response rate was 93.3% (n = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast. CONCLUSIONS: The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.

With equity in mind: Evaluating an interactive hybrid global surgery course for cross-site interdisciplinary learners.

There is limited understanding of the role of transcultural, cross-site educational partnerships for global surgery training between high- and low- or middle-income country (LMIC) institutions. We describe the development, delivery, and appraisal of a hybrid, synchronous, semester-long Global Surgical Care course by global health collaborators from widely different contexts, and evaluate the equity of the collaboration. The course was collaboratively modified by surgical educators and public health professionals with emphasis on collaboration ethics. Faculty from high-income and LMICs were paired to deliver lectures. To collaborate internationally, students and faculty participated either onsite or online. Perceptions and knowledge gained were quantitatively evaluated through participant and faculty cross-sectional surveys, using Likert scales, prioritization rankings, and free text responses analysed qualitatively. Equity was assessed using the Fair Trade Learning rubric and additional probes. Thirty-five learners from six institutions participated. Teams produced mock National, Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) for selected LMICs, and reported a 9% to 65% increase in self-reported global health competencies following the course. Online learners had favourable perceptions of learning, but experienced connectivity challenges. Barriers to effective group work included time differences and logistics of communication for dispersed team members. Individuals taking the course for academic credit scored significantly higher than other learners in peer assessments of participation (8.56±1.53 versus 5.03±3.14; p<0.001). Using the Fair Trade Rubric, 60% of equity indicators were ideal, and no respondents perceived neo-colonialism in the partnership. Blended, synchronous, interdisciplinary global surgery courses based on "North-South" partnerships with a focus on equity in design and delivery are feasible but require careful and deliberate planning to minimize epistemic injustice. Such programs should address surgical systems strengthening, and not create dependency. Equity in such engagements should be evaluated and monitored in an ongoing fashion to stimulate discussion and continuous improvement.

Assessment of resource capacity and barriers to effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA).

BACKGROUND: The adoption and accessibility of laparoscopy have been serious issues in countries with limited resources, and for varied reasons. This study assessed resource capacity and barriers to the effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). METHODS: A multi-country survey was conducted from January 2021 to October 2021 using a questionnaire distributed to surgeons in COSECSA hospitals located in 16 different countries. Available resources and surgical volume were assessed, and the barriers to routinely performing laparoscopy were determined. RESULTS: Ninety-four surgeons working in 44 different hospitals from 16 countries participated in the survey. The majority of respondents were general surgeons (n = 75, 79.7%). Other specialties included urology (n = 12, 12.8%) and pediatric surgery (n = 7, 7.4%). Senior surgeons accounted for 60.6% of participants, more than 40% had a managerial position and approximately 20% were surgical trainees. Most respondents practiced in public hospitals (n = 66, 70.2%). A median of three surgeons per hospital performed laparoscopic surgery with, on average, two laparoscopic towers and two sets of laparoscopic instruments available. A median of 10 procedures was carried out per month. The cost of laparoscopic procedures and laparoscopic consumables were reported as being covered by some health insurance payments in 76.9% and 48.4% of cases, respectively. Cholecystectomy was the most commonly reported laparoscopic procedure performed. The five top barriers to performing laparoscopic surgery were: a lack of consumables, a limited quantity of equipment, a lack of skilled surgeons, the high cost of laparoscopic procedures and complicated cases. In addition, having access to skilled anesthesiologists and anesthesia equipment, carbon dioxide, a consistent electric power supply and equipment maintenance were cited as significant challenges. CONCLUSION: The practice of laparoscopy is currently limited in COSECSA countries due to a scarcity of skilled staff and the lack of a funding plan to make laparoscopic services accessible. Therefore, policymakers and stakeholders should take strategic measures to respond to this need.