Peer-teaching at the University of Rwanda - a qualitative study based on self-determination theory.

BACKGROUND: Peer-teaching is an educational format in which one student teaches one, or more, fellow students. Self-determination theory suggests that intrinsic motivation increases with the enhancement of autonomy, competence and relatedness. AIMS: This qualitative study sought to explore and better understand the lived experiences, attitudes and perceptions of medical students as peer-teachers at the University of Rwanda when participating in a peer-learning intervention in the pediatric department. METHODS: Students participated in a 3-h peer-taught symposium, supervised by a pediatric specialist or resident. Students worked in small groups to deliver a short didactic presentation related to acute illness in children. The symposium prepared the students for simulation-based teaching activities. In-depth, semi-structured, interviews were then employed to explore the students' experiences of the peer-teaching symposium. We specifically aimed to scaffold the analysis of these experiences on the themes of autonomy, competence and relatedness. RESULTS: Saturation was achieved after interviews with ten students. Students described developing their own autonomous learning strategies, but despite developing this autonomy had a desire for support in the delivery of the sessions. Competence was developed through enhanced learning of the material, developing teaching skills and confidence in public speaking. Students valued the different aspects of relatedness that developed through preparing and delivering the peer-teaching. Several other themes were identified during the interviews, which are not described here, namely; i. Satisfaction with peer-teaching; ii. Peer-teaching as a concept; iii. Practical issues related to the peer-teaching session, and iv. Teaching style from faculty. CONCLUSIONS: This is the first study to assess peer-learning activities in Rwanda. It has used qualitative methods to deeply explore the lived experiences, attitudes and perceptions of medical students. The peer-teaching strategy used here demonstrates the potential to enhance intrinsic motivation while increasing knowledge acquisition and teaching skills. We postulate that students in resource-limited settings, similar to Rwanda, would benefit from peer-teaching activities, and in doing so could enhance their intrinsic motivation.

Using a Global Health Media Project Video to Increase Knowledge and Confidence in the Mothers of Admitted Neonates in Rwanda: A Prospective Interventional Study.

INTRODUCTION: In resource-limited settings, the ratio of trained health care professionals to admitted neonates is low. Parents therefore, frequently need to provide primary neonatal care. In order to do so safely, they require effective education and confidence. The evolution and availability of technology mean that video education is becoming more readily available in this setting. AIM: This study aimed to investigate whether showing a short video on a specific neonatal topic could change the knowledge and confidence of mothers of admitted neonates. METHODS: A prospective interventional study was conducted in two hospitals in Kigali, Rwanda. Mothers of admitted neonates at a teaching hospital and a district hospital were invited to participate. Fifty-nine mothers met the inclusion criteria. Participants were shown 'Increasing Your Milk Supply, for mothers' a seven-minute Global Health Media Project video in the local language (Kinyarwanda). Before and after watching the video, mothers completed a Likert-based questionnaire which assessed confidence and knowledge on the subject. RESULTS: Composite Likert scores showed a statistically significant increase in knowledge (pre = 27.2, post = 33.2, p < 0.001) and confidence (pre = 5.9, post = 14.2, p < 0.001). Satisfaction levels were high regarding the video content, language and quality. However, only 10% of mothers owned a smartphone. DISCUSSION: We have shown that maternal confidence and knowledge on a specific neonatal topic can be increased through the use of a short video and these videos have the potential to improve the quality of care provided to admitted neonates by their parents in low-resource settings.

Perceived attitudes of the importance and barriers to research amongst Rwandan interns and pediatric residents - a cross-sectional study.

BACKGROUND: Globally, interns and residents face significant challenges with respect to research activity. Despite this, they are motivated and have an interest in undertaking research. To date, there has been no research regarding the perceived attitudes towards research activities amongst Rwandan residents and interns. OBJECTIVES: The primary objective of this study was to describe the perceived attitudes regarding the educational benefits and barriers surrounding research activity amongst interns and residents, and to identify any differences between these groups. The secondary objective was to describe the research methods used by interns and residents in Rwanda. METHODS: A cross-sectional descriptive study of interns and pediatric trainees at the University of Rwanda. An online questionnaire using Likert scale questions was sent electronically to eligible participants. RESULTS: A total of sixty participants (38 interns and 22 pediatric residents) responded to the survey. Both groups acknowledged the educational importance of undertaking research, with interns reporting this more than residents. Both groups identified the following as barriers to research: faculty lacking time to mentor, lack of funding, lack of statistical support, and lack of faculty experienced in conducting research. Interns (87%) were much more likely to have undertaken retrospective research than pediatric residents (14%). Few interns or residents submitted their research for publication (27%). CONCLUSIONS: Both interns and residents understood the importance of research, but many barriers exist. Increasing the time available for experienced faculty members to supervise research is challenging due to low faculty numbers. Novel solutions will need to be found as well as expanding the time for trainees to perform research.

Measuring change in knowledge acquisition of Rwandan residents: using the American Board of Pediatrics International In-Training Examination (I-ITE) as an independent tool to monitor individual and departmental improvements during the Human Resources for Health program: an observational study.

BACKGROUND: Rwanda is the only African country to use the pediatric International In-Training Examination (I-ITE). The objectives of this study were to use the scores from the I-ITE to outline the baseline level of knowledge of Rwandan residents entering the pediatric residency and the trends in knowledge acquisition from 2012 to 2018, during the Human Resources for Health (HRH) Program, an education partnership between the Rwanda Ministry of Health and a consortium of US universities. METHODS: A retrospective descriptive analysis of the I-ITE exam scores, taken by all Rwandan pediatric residents for five of the six academic years of the study period. Individual resident scores were weighted using the non-Rwandan I-ITE sites to minimise confounding from annual variations in exam difficulty. Statistical analysis included descriptives with ANOVA to compare variation in annual mean scores. RESULTS: Eighty-four residents took 213 I-ITE exam sittings over the five exam cycles. The mean weighted I-ITE score of all residents increased from 34% in 2013 to 49% (p < 0.001) in 2018. The 32-point gap between the mean US-ITE and Rwandan I-ITE score in 2012-2013 was reduced to a 16-point gap in 2017-2018. First year resident (PG1) scores, which likely reflect the knowledge level of undergraduate medical students entering the residency program, increased from 34.8 to 44.3% (p = 0.002) between 2013 and 2018. CONCLUSIONS: The I-ITE is an independent, robust tool, measuring both learners and the institutional factors supporting residents. This is the first study to demonstrate that the I-ITE can be used to monitor resident knowledge acquisition in resource-limited settings, where assessment of resident knowledge can be a major challenge facing the academic medicine community. The significant increase in I-ITE scores between 2012 and 18 reflects the substantial curricular reorganisation accomplished through collaboration between Rwandan and US embedded faculty and supports the theory that programs such as HRH are highly effective at improving the quality of residency programs and undergraduate medical education.

Global Health Journal Club: Is Honey Effective as a Treatment for Chemotherapy-induced Mucositis in Paediatric Oncology Patients?

Oral mucositis (OM) is an inflammatory response of mucosal epithelium to the cytotoxic effects of chemotherapy and radiotherapy causing severe oral pain and ulceration, which may complicate the management of cancer. The Mucositis Prevention Guideline Development Group has developed an international guideline for the prevention of mucositis in children receiving treatment for cancer or undergoing haematopoietic stem cell transplantation. Evidence-based preventative strategies include cryotherapy, low-level light therapy and keratinocyte growth factor. However, these strategies are often not available in resource-poor settings. There is some evidence that honey may be a suitable treatment for OM in adult patients. We performed a literature search of 11 databases to find papers exploring the use of honey to treat chemotherapy-associated mucositis in paediatric oncology patients. We found four papers, which provide Grade C evidence that honey is effective as a preventative and therapeutic measure for OM in paediatric oncology patients.

The use of social-networking sites in medical education.

BACKGROUND: A social-network site is a dedicated website or application which enables users to communicate with each other and share information, comments, messages, videos and images. AIMS: This review aimed to ascertain if "social-networking sites have been used successfully in medical education to deliver educational material", and whether "healthcare professionals, and students, are engaging with social-networking sites for educational purposes". METHOD: A systematic-review was undertaken using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eight databases were searched with pre-defined search terms, limits and inclusion criteria. Data was extracted into a piloted data-table prior to the narrative-synthesis of the Quality, Utility, Extent, Strength, Target and Setting of the evidence. RESULTS: 1047 articles were identified. Nine articles were reviewed with the majority assessing learner satisfaction. Higher outcome measures were rarely investigated. Educators used Facebook, Twitter, and a custom-made website, MedicineAfrica to achieve their objectives. CONCLUSIONS: Social-networking sites have been employed without problems of professionalism, and received positive feedback from learners. However, there is no solid evidence base within the literature that social-networking is equally or more effective than other media available for educational purposes.

Is HINARI appropriate for medical students in the developing world?

The Health InterNetwork Access to Research Initiative (HINARI), which arose in response to medical literature needs in developing countries, gives online access to scientific information to a variety of institutions throughout the world. This is a great resource; however, little research has been performed on the effectiveness and usefulness of HINARI, specifically to medical schools. Our study sought to find out whether the textbooks (e-books) available on HINARI could form a virtual library that would cover the curriculum of a medical school. After categorising and reviewing the medically relevant e-books on HINARI, we found that they were insufficient in providing adequate subject material relevant to medical school curricula from Rwanda, the United Kingdom and the United States. This literature gap could be closed by additional medical textbooks being made available from contributing publishers. An increase of only 14% in HINARI e-book resources would provide material for the entire medical school curriculum.

Closing the communication gap in neonatal inter-hospital transfer: a neonatal referral form for resource-limited settings - a modified e-Delphi-consensus study.

Background: Standardised neonatal referral forms (NRFs) facilitate effective communication between healthcare providers and ensure continuity of care between facilities, which are essential for patient safety. We sought to determine the essential data items, or core clinical information (CCI), that should be conveyed for neonatal inter-hospital transfer in resource-limited settings (Rounds 1 to 3) and to create an NRF suitable for our setting (Round 4). Methods: We conducted an international, four-round, modified Delphi-consensus study. Round-1 was a literature and internet search to identify existing NRFs. In Round-2 and -3, participants were Rwandan clinicians and international paediatric healthcare practitioners who had worked in Rwanda in the five years before the study. These participants evaluated the draft items and proposed additional items to be included in an NRF. Round-4 focused on creating the NRF and used five focus groups of Rwandan general practitioners at district hospitals. Results: We identified 16 pre-existing NRFs containing 125 individual items. Of these, 91 items met the pre-defined consensus criteria for inclusion in Round-2. Only 33 items were present in more than 50% of the 16 NRFs, confirming the need for this consensus study. In Round-2, participants proposed 12 new items, six of which met the pre-defined consensus criteria. In Round-3, participants scored items for importance, and 57 items met the final consensus criteria. In Round-4, 29 general practitioners took part in five focus groups; a total of 16 modifications were utilised to finalise the NRF. Conclusions: We generated a novel, robust, NRF that may be readily employed in resource-limited settings to communicate the essential clinical information to accompany a neonate requiring inter-hospital transfer.

Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda - a validation and inter-rater reliability study.

INTRODUCTION: There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap. OBJECTIVES: to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1-12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used. METHODS: A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant. RESULTS: 100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98-0.99) and 0.980 (0.97-0.99). The convergent validity (Pearson's correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92-0.99, p<0.001) and 0.880 (CI: 0.80-0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively. CONCLUSION: LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.

Prevalence, risk factors and outcomes of neonatal hypothermia at admission at a tertiary neonatal unit, Kigali, Rwanda - a cross-sectional study.

INTRODUCTION: Thermoregulation remains a key physiological challenge faced by a neonate after delivery. We assessed the prevalence, risk factors and outcomes of hypothermia in admitted neonates at a tertiary teaching hospital of Kigali city in Rwanda. MATERIALS AND METHODS: A cross-sectional study was conducted, from July 2013 to September 2017, of neonates who were admitted in the neonatology unit of the University Teaching Hospital of Kigali (CHUK) and whose admission temperature were recorded. Data were extracted from the neonatal database (registry). RESULTS: The neonatal database contained 1021 eligible neonates of which 15% were outborn. Hypothermia was found at admission in 280 of the 1021 eligible neonates (27%). The extremely preterm (<28 weeks) were significantly more likely to become hypothermic compared to term neonates (AOR = 6.81, CI: 3.39-13.71, p < .001). Mortality rate was higher in hypothermic infants (AOR = 1.89, CI: 1.16-3.1, p = .011). Length of hospital stay (22 versus 13 days, p < .001), in all surviving infants was higher in neonates admitted hypothermic, though not in the subgroups of infants < 32-week gestation. DISCUSSION: Thermal protection of the neonate immediately after birth is essential. In our tertiary neonatal unit, we identify nearly one-third of neonates are hypothermic at admission and this is associated with higher mortality and increased length of hospital stay. The ten-steps of the WHO "warm chain" may present an analytic roster for maternity and neonatal teams to pinpoint targets for interventional research and quality improvement work in order to achieve better outcomes.

Cow's milk protein allergy.

CMPA is a common food allergy that presents with diverse manifestations affecting more than one body system. Early recognition of the condition and prompt initiation of dietary elimination of cow's milk protein is important. A future challenge with cow's milk protein can confirm a positive diagnosis.

Pediatric self-medication use in Rwanda - a cross sectional study.

BACKGROUND: Self-medication, a worldwide practice, has both benefits and risks. Many countries have regulated non-prescription medications available for use in self-medication. However, in countries such as Rwanda, where prescriptions are not required to purchase medications, prescription, non-prescription and traditional medications have been used for self-medication. OBJECTIVES: To determine the reported self-medication use in Rwanda and to determine attitudes and reasons associated with parental decisions to self-medicate their children. METHODS: A cross-sectional multi-center questionnaire based quantitative study of 154 parents/caregivers of children under ten years undertaken in private and public health facilities. RESULTS: The use of self-medication was reported to be 77.9%. Among these parents/caregivers, 50.8% used modern self-medication only, 15.8% used traditional self-medication only and 33.3% used both types of self-medication. Paracetamol was the most commonly used drug in modern self-medication; the traditional drugs used were Rwandan local herbs. Parents/caregivers who used modern medicines had slightly more confidence in self-medication than self-medication users of traditional medicines (p=0.005). Parents/caregivers who used modern self-medication reported barriers to consultation as a reason to self-medicate more frequently than those who used traditional drugs. Having more than one child below 10 years of-age was the only socio-demographic factor associated with having used self-medication (AOR=4.74, CI: 1.94-11.58, p=0.001). Being above 30 years (AOR= 5.78, CI: 1.25-26.68, p=0.025) and living in Kigali (AOR=8.2, CI: 1.58-43.12, p=.0.012) were factors associated with preference of modern self- medication compared to traditional self-medication. CONCLUSION: Self-medication is common in Rwanda. Parents/caregivers are involved in this practice regardless of their socio-demographic background.

Medical student satisfaction and confidence in simulation-based learning in Rwanda - Pre and post-simulation survey research.

INTRODUCTION: Simulation-based learning (SBL) has been shown to effectively improve medical knowledge, procedural proficiency, comfort with undertaking taught tasks, inter-professional communication, teamwork and teaching skills. This study aimed to evaluate Rwandan medical students' attitudes, satisfaction and confidence level with SBL. METHODS: Fifth year medical students at the University of Rwanda were given a short course on paediatric acute care using simulation. The simulation sessions were locally developed cases based on the pRRAPID materials, developed at the University of Leeds (UK). Equipment included low fidelity infant mannequins, basic airway devices, IV access, and monitoring. A four-part, Likert-scale questionnaire was distributed to medical students before and after their four-week simulation program. RESULTS: 57 pre-simulation and 49 post-simulation questionnaires were completed. Confidence in skills increased in all fifteen domains of the questionnaire with the total skill confidence score rising from 44.0 (±12.3) to 56.2 (±8.8) after the simulation-based intervention (p < 0.001). Satisfaction and attitudes towards simulation-based learning in this setting were very positive. CONCLUSION: The simulation-based intervention was well received by students in this setting. Satisfaction was high and the simulation exercise increased the students' confidence. Previous research has demonstrated that SBL is effective and the results of this study now demonstrate that it is well received in our setting. As we move from knowledge-based education to a competency-based education culture, faculties in this setting should invest in providing SBL opportunities throughout the medical school curriculum.