Barriers and facilitators of research in Cameroon (Part II) – an e-survey of medical students

Introduction: research fosters critical thinking and prepares students for a career in academic medicine. This study aimed to identify the facilitators and barriers to research among Cameroonian medical students.

Methods: an electronic survey was distributed between May 23, 2020, and June 07, 2020. The survey was made of closed-, opened-, and Likert scale questions. A Preference Score (PS) was used to quantify the medical students’ perception of barriers and facilitators to research. The Kruskal-Wallis H and Fisher’s Exact tests were used to evaluate bivariate relationships

Results: one hundred and eighty-eight (188) students with a mean age of 24.1 ± 2.3 years were enrolled. Most respondents were male (56.9%), francophone (69.1%), and in their final year of medical school (46.8%). Twenty-one students (11.1%) had a peer-reviewed article, and all the published students were in their sixth- or seventh-year of undergraduate medical studies. Barriers to research included lack of funding (PS=203), obsolete patient information management systems (PS=198), and limited understanding of biostatistics (PS=197). Facilitators to research included research focused on the student’s interests (PS=255), the study’s capacity to improve practice (PS=247), and scientific recognition (PS=198).
Conclusion: barriers to research among Cameroonian medical students are mainly institutional. However, facilitators are primarily linked to career goals. To improve research activities among these undergraduates, initiatives must target institutional barriers and incentives that foster career development.

Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.

Establishing a Sustainable Training Program for Laparoscopy in Resource-Limited Settings: Experience in Ghana

Background:
Healthcare equipment funded by international partners is often not properly utilized in many developing countries due to low levels of awareness and a lack of expertise. A long-term on-site training program for laparoscopic surgery was established at a regional hospital in Ghana upon request of the Ghana Health Service and local surgeons.

Objective:
The authors report the initial 32-month experience of implementing laparoscopic surgery focusing on the trainees’ response, technical independence, and factors associated with the successful implementation of a “new” surgical practice.

Methods:
Curricular structure and feedback results of the trainings for doctors and nurses, and characteristics of laparoscopic procedures performed at the Greater Accra Regional Hospital between January 2017 and September 2019 were retrospectively reviewed.

Findings:
Comprehensive training including two weeks of simulation workshops followed by animal labs were regularly provided for the doctors. Among the 97 trainees, 27.9% had prior exposure in laparoscopic surgery, 95% were satisfied with the program. Eleven nurses attained professional competency over 15 training sessions where none had prior exposure to laparoscopic surgery. Since the first laparoscopic cholecystectomy in February 2017, 82 laparoscopic procedures were performed. The scope of the surgery was expanded from general surgery (n = 46) to gynecology (n = 33), pediatric surgery (n = 2), and urology (n = 1). The volume of local doctors as primary operators increased from 0% (0/17, February to December 2017) to 41.9% (13/31, January to October 2018) and 79.4% (27/34, November 2018 to September 2019), with 72.5% of the cases being assisted by the expatriate surgeon. There were no open conversions, technical complications, or mortalities. Local doctors independently commenced endoscopic surgical procedures including cystoscopies, hysteroscopies, endoscopic neurosurgeries and arthroscopies.

Conclusion:
Sensitization and motivation of the surgical workforce through long-term continuous on-site training resulted in the successful implementation of laparoscopic surgery with a high level of technical independence.

Outcomes of trauma education workshop in Vietnam: improving diagnostic and surgical skills

Background
Unintentional injuries have emerged as a significant public health issue in low- and middle-income countries (LMIC), especially in Vietnam, where there is a poor quality of care for trauma. A scarcity of formal and informal training opportunities contributes to a lack of structure for treating trauma in Vietnam. A collaborative trauma education project by the JW LEE Center for Global Medicine in South Korea and the Military Hospital 175 in Vietnam was implemented to enhance trauma care capacity among medical staff across Ho Chi Minh City in 2018. We aimed to evaluate a part of the trauma education project, a one-day workshop that targeted improving diagnostic and surgical skills among the medical staff (physicians and nurses).

Methods
A one-day workshop was offered to medical staff across Ho Chi Minh City, Vietnam in 2018. The workshop was implemented to enhance the trauma care knowledge of providers and to provide practical and applicable diagnostic and surgical skills. To evaluate the workshop outcomes, we utilized a mixed-methods survey data. All participants (n = 27) voluntarily completed the post-workshop questionnaire. Quality of contents, satisfaction with teaching skills, and perceived benefit were used as outcomes of the workshop, measured by 5-point Likert scales (score: 1–5). Descriptive statistics were performed, and open-ended questions were analyzed by recurring themes.

Results
The results from the post-workshop questionnaire demonstrated that the participants were highly satisfied with the quality of the workshop contents (mean = 4.32 standard deviation (SD) = 0.62). The mean score of the satisfaction regarding the teaching skills was 4.19 (SD = 0.61). The mean score of the perceived benefit from the workshop was 4.17 (SD = 0.63). The open-ended questions revealed that the program improved their knowledge in complex orthopedic surgeries neglected prior to training.

Conclusions
Positive learning experiences highlighted the need for the continuation of the international collaboration of skill development and capacity building for trauma care in Vietnam and other LMIC.

Mobile technologies to support healthcare provider to healthcare provider communication and management of care

Background: The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes.

Objectives: To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers’ performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties.

Search methods: We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts.

Selection criteria: Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care.

Data collection and analysis: We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence.

Main results: We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: – probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); – probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); – may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); – probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; – may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; – may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: – probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); – probably reduce participants’ length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers’ adherence, participants’ health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: – probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); – may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); – may make little or no difference to participants’ disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); – probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers’ adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs.

Authors’ conclusions: Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants’ health status and well-being, satisfaction, or costs.

COVID-19’s Impact on Neurosurgical Training in Southeast Asia

Objective: Neurosurgery departments worldwide have been forced to restructure their training programs due to the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia.

Methods: We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from 22 to 31 May 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.

Results: A total of 298 out of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median=100% for both) was significantly greater compared with other countries (p <.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median=80% and 70%, respectively) compared with trainees in Singapore and Thailand (median=20% and 50%, respectively, p <.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.

Conclusions: An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories, to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.

The Effectiveness and Challenges of E-learning in Surgical Training in Low- and Middle-Income Countries: A Systematic Review

E-learning encompasses the use of electronic media, online tools, and technologies in education and has been shown to be generally effective and satisfying for students, compared to traditional methods such as didactic lectures. Within surgical education, there is growing demand for e-learning platforms in low- and middle-income countries (LMICs). A systematic review was conducted to evaluate the effectiveness and challenges of e-learning for surgical trainees in LMICs. Out of 87 studies, five studies met the inclusion criteria and reported either neutral or positive improvements in cognitive and procedural skills, compared to baselines or controls for surgical trainees in LMICs. Using a qualitative synthesis approach, the researchers identified common challenges and barriers, such as low bandwidth, limited connectivity, and poor surgical details, which led to poor knowledge synthesis. This suggests that more emphasis needs to be placed on developing a strong online foundation that could be easily accessed and is user-friendly and intuitive, especially in LMICs. However, the research was limited by the lack of literature surrounding surgical e-learning interventions in LMICs and more research is required in this area.

Remote Monitoring of Clubfoot Treatment With Digital Photographs in Low Resource Settings: Is It Accurate?

Background: Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment.

Methods: In this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as ‘success’, ‘borderline’ or ‘failure’. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score.

Results: There was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%-88.3% and specificity ranged from 57.9%-73.3%.

Conclusion: Digital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings.

COVID-19 and Neurosurgical Education in Africa: Making Lemonade From Lemons

Never in history has the fabric of African Neurosurgery been challenged as it is today with the advent of covid-19. Even the most robust and resilient neurosurgical educational systems in the continent have been brought to their knees with Neurosurgical trainees and young neurosurgeons bearing the brunt. In the face of this new reality, and in order to limit the impact of the current COVID-19 pandemic, multiple programs have implemented physical distancing which reduces in-person interactions. In some cases, residents have been asked to stay home at least till they are instructed otherwise. This unfortunate event presents an innovative opportunity for neurosurgical education in Africa. Herein, we detail the framework of an online neurosurgical education initiative to advance the education of African residents and young Neurosurgeons during and after the COVID-19 pandemic.

The Occurrence and Contributing Factors of Needle Stick and Sharp Injuries Among Dental Students in a South African University

Background:
Needle stick and sharp injuries are a global public health issue, mainly due to exposure to infectious diseases. Dental students, in particular, are at a high risk of needle stick and sharp injuries attributed to the restricted working space of the oral cavity and the routine use of sharp instruments, among other risks. Despite this growing body of knowledge on needle stick and sharp injuries in the dental setting, data is limited among dental students in South Africa.

Objective:
The study aimed to determine the occurrence and contributing factors of needle stick and sharp injuries among dental undergraduate students in a university in South Africa.

Methods:
A university based cross-sectional study was conducted among 248 dental students in the School of Oral Health Sciences using a census sampling. An anonymous self-administered questionnaire was used to collect data on prevalence, procedures, instruments, reporting, contributing factors, training, protective strategies, and hepatitis B immunization. Data was analysed using STATA 14.

Results:
The response rate was 99% and the mean age of students was 24 years (SD=±4). Male students were 43% (107), while females constituted 57% (141) of the sample. One-hundred and one (41%) students reported being exposed to needle stick and sharps injuries. Most injuries (45%) occurred among students studying Bachelor of Dental and Surgery and among students in the 4th year (57%). The people at the departments of periodontology (39%), and maxillofacial and oral Surgery (25%) experienced most injuries. The main tools causing injuries were the syringe needle (52%) and the scaler (31%) while injecting a patient (34%), and scaling and polishing (26%) were common procedures. Eight (8%) students did not report their injury, even though the use of prophylaxis exposure was minimal (8%). Very few students (5%) were tested for a blood-borne virus after injury, while 23% did nothing with their injury and 43% opted to wash the injury under tap water. Lack of concentration (36%) and anxiety (19%) were reported as major contributing factors to injuries. Two hundred and forty six (99%) students were fully vaccinated against hepatitis B. Two hundred and nineteen (86%) students were aware of full details on the use of universal precautions. One hundred and eighty six (75%) students practiced needle recapping. Being in the 3rd year (AOR = 3.0, 95%CI: 1.4 – 6.3), 4th year (AOR = 5.0, 95%CI: 1.9 – 11) and 5th year (AOR=4.6, 95%CI: 2 -12.5) was significantly associated to injuries compared to students in the 2nd year of the study.

Conclusion:
The needle stick and sharp injuries were prevalent in this study, and factors implicated were lack of concentration and anxiety, as well as, age, academic year of study and training on handling of instruments. The burden of needle stick and sharps injuries among the dental professionals can be reduced by adhering to the current and universally accepted standard precautionary measures against needle stick and sharp injuries.