Implementing surgical mentorship in a resource-constrained context: a mixed methods assessment of the experiences of mentees, mentors, and leaders, and lessons learned

Background
A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource–constrained settings.

Methods
We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes.

Results
All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention.

Conclusion
We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention’s success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

Virtual reality technology in linked orthopaedic training in Ethiopia

Introduction
We describe the feasibility of delivering a live orthopaedic surgical teaching session with virtual reality (VR) technology simultaneously for trainee surgeons in Ethiopia and the UK.

Methods
Forty-three delegates from the Severn Deanery in the UK (n=30) and Bahir Dar in Ethiopia (n=13) attended a live training session in February 2021. During the session, participants watched a surgical operation (recorded earlier that week with a 360° VR camera) alongside live commentary. A qualitative questionnaire was distributed to gauge feasibility, connectivity and educational value of the session as well as its VR component.

Results
The majority of delegates from both the UK and Ethiopia felt that the use of VR technology to aid surgical training is feasible, that it is useful for learning surgical approaches, that it aids surgical performance and that it is superior to conventional resources. Bahir Dar residents strongly agreed that VR simulation videos would allow trainees to supplement reduced learning opportunities as a result of the COVID-19 pandemic and help to counteract their reduced operating experience. For Bahir Dar trainees, a lack of a stable internet connection for large VR files was the predominant issue.

Conclusions
This study demonstrates that there are infrastructure challenges in low and middle income countries (LMICs) in terms of the reliable delivery of VR teaching in orthopaedics at the current time. Despite this, our findings better inform the potential role of VR technology in surgical education, and shed light on the possibility for it to feed into and enrich surgical training in both LMICs and high income countries.

Qualitative Analysis of the Host-Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange

Background
As globalization of surgical training increases, growing evidence demonstrates a positive impact of global surgery experiences on trainees from high-income countries (HIC). However, few studies have assessed the impact of these largely unidirectional experiences from the perspectives of host surgical personnel from low- and middle-income countries (LMIC). This study aimed to assess the impact of unidirectional visitor involvement from the perspectives of host surgical personnel in Kijabe, Kenya.

Methods
Voluntary semi-structured interviews were conducted with 43 host surgical personnel at a tertiary referral hospital in Kijabe, Kenya. Qualitative analysis was used to identify salient and recurring themes related to host experiences with visiting surgical personnel. Perceived benefits and challenges of HIC involvement and host interest in bidirectional exchange were assessed.

Results
Benefits of visitor involvement included positive learning experiences (95.3%), capacity building (83.7%), exposure to diverse practices and perspectives (74.4%), improved work ethic (51.2%), shared workload (44.2%), access to resources (41.9%), visitor contributions to patient care (41.9%), and mentorship opportunities (37.2%). Challenges included short stays (86.0%), visitor adaptation and integration (83.7%), cultural differences (67.4%), visitors with problematic behaviors (53.5%), learner saturation (34.9%), language barriers (32.6%), and perceived power imbalances between HIC and LMIC personnel (27.9%). Nearly half of host participants expressed concerns about the lack of balanced exchange between HIC and LMIC programs (48.8%). Almost all (96.9%) host trainees expressed interest in a bidirectional exchange program.

Conclusion
As the field of global surgery continues to evolve, further assessment and representation of host perspectives is necessary to identify and address challenges and promote equitable, mutually beneficial partnerships between surgical programs in HIC and LMIC.

Access to training in neurosurgery (Part 2): The costs of pursuing neurosurgical training

Introduction
Opportunities for in-country neurosurgical training are severely limited in LMICs, particularly due to rigorous educational requirements and prohibitive upfront costs.

Research question
This study aims to evaluate financial barriers aspiring neurosurgeons face in accessing and completing neurosurgical training, specifically in LMICs, in order to determine the barriers to equitable access to training.

Material and methods
In order to assess the financial costs of accessing and completing neurosurgery residency, an electronic survey was administered to those with the most recent experience with the process: aspiring neurosurgeons, neurosurgical trainees, and recent neurosurgery graduates. We attempted to include a broad representation of World Health Organization (WHO) geographic regions and World Bank income classifications in order to determine differences among regions and countries of different income levels.

Results
Our survey resulted in 198 unique responses (response rate 31.3%), of which 83% (n ​= ​165) were from LMICs. Cost data were reported for 48 individual countries, of which 26.2% were reported to require trainees to pay for their neurosurgical training. Payment amounts varied amongst countries, with multiple countries having costs that surpassed their annual gross national income as defined by the World Bank.

Discussion and conclusions
Opportunities for formal neurosurgical training are severely limited, especially in LMICs. Cost is an important barrier that can not only limit the capacity to train neurosurgeons but can also perpetuate inequitable access to training. Additional investment by governments and other stakeholders can help develop a sufficient workforce and reduce inequality for the next generation of neurosurgeons worldwide.

Economic Evaluation of a Global Reconstructive Surgery Visiting Educator Program

Objective:
The objective of this study was to quantify the cost-effectiveness and economic value of a reconstructive surgery visiting educator trip program in a resource-constrained setting.

Background:
Reconstructive surgical capacity remains inadequate in low- and middle-income countries, resulting in chronic disability and a significant economic toll. Education and training of the local surgical workforce to sustainably expand capacity have been increasingly encouraged, but economic analyses of these interventions are lacking.

Methods:
Data were analyzed from 12 visiting educator trips and independently-performed surgical procedures at 3 Vietnamese hospitals between 2014 and 2019. A cost-effectiveness analysis was performed using standardized methodology and thresholds to determine cost-effectiveness. Sensitivity analyses were performed with disability weights, discounting, and costs from different perspectives. Economic benefit was estimated using both the human capital method and the value of a statistical life method, and a benefit-cost ratio was computed.

Results:
In the base case analysis, the visiting educator program was very cost-effective at $581 per disability-adjusted life year (DALY) averted. Economic benefit was between $21·6 million and $29·3 million, corresponding to a 12- to 16-fold return on investment. Furthermore, when considering only costs to the organization, the cost decreased to $61 per DALY averted, with a 113- to 153-fold return on investment for the organization.

Conclusions:
Visiting educator programs, which build local reconstructive surgical capacity in limited-resource environments, can be very cost-effective with significant economic benefit and return on investment. These findings may help guide organizations, donors, and policymakers in resource allocation in global surgery.

Decolonizing Global Surgery

By bringing health professionals across a variety of disciplines together, we are able to share strategies and create solutions for improving surgical care to these under-serviced regions. The Bethune Round Table 2022 took place virtually, June 16 – 19 and was hosted by BGSC,in co-operation with the Canadian Network for International Surgery. The theme for the BRT 2022 was “Decolonizing Global Surgery”.

The conference program consisted of 28 panelists and speakers and 98 abstracts (46 podium presentations and 52 posters) touching upon diverse aspects of global surgery including women in surgery, indigenous health, and sustainability in global partnerships. All sessions were recorded, including abstracts. All the abstracts presented are contained within this document.

Publication dynamics: what can be done to eliminate barriers to publishing full manuscripts by the postgraduate trainees of a low-middle income country?

Objectives
This study aimed to determine the publication rate of free paper abstracts presented by the postgraduate (PG) trainees and determine the reasons for non-publication. A mixed methods study was conducted. PG trainees presenting free papers at the at the Pakistan Society of Chemical Pathologist conferences from 2012 to 2018 were included. Three databases were searched to identify if the abstracts were published or not. The PG trainee authors of abstracts not published as full manuscript, were surveyed to determine the barriers and challenges in publishing a manuscript.

Results
The average rate of full manuscript publication was 51.8% (n = 93/177) for the abstracts presented by the PG trainees. Publication rate was higher for oral (n = 73/119, 61.3%) compared to poster presentation (n = 20/58, 34.5%). Most of the manuscripts were published after two years of abstract presentation. The survey showed that the main challenges to publishing an abstract were lack of time, limited scientific writing or submission skills, lack of funding for publication fee, and negative or statistically non-significant results. This reflects a need to arrange workshops/symposia for the PG trainees of low-middle income country (LMIC) to enhance their writing and time management skills and improve the full manuscript publication rate from LMICs.

Knowledge and practice of Nepalese doctors on reutilization of medical/surgical tools from developed nations: a national level online cross-sectional survey

Background:
A manifold cause of global disparity in medical and surgical care exists, among which lack of access to proper biomedical equipment including surgical tools are a recurrent theme. Use and reuse of such donated tools are common in low resource settings including countries like Nepal; however, there is a lack of adequate data and less has been explored. Through this nationwide study, we aimed to discover the knowledge of donated medical and surgical devices and the practice of reusing single-use equipment by Nepalese medical practitioners and surgeons.

Methods:
An online, questionnaire-based cross-sectional study was conducted using SurveyMonkey from October 2020 through January 2021. The link was sent to target respondents via email and social media and responses were recorded. Data processing and analysis were done using the same platform.

Results:
Among 466 respondents, 349 completed the survey. Around 81.5% recorded that their institute has never received medical devices or donations in the past, while 18.34% believed they had received such commodities. Most of the donations were received from countries like the United States, China, Japan, and India. Around 24% of the respondents reused the tools meant for single-use and only 5% communicated with the donors. Commodities like laparoscopic sets, sutures, dialysis machines, magnetic resonance imaging machines, surgical retractors, face masks, sanitizers, personal protective equipment, endoscopy apparatus, etc., were received. The majority of them were concerned about national guidelines regarding donating reusable tools which might not be acceptable through custom rules of the country, although the facilitation of functional yet unused tools is always welcome in the underserved regions of Nepal.

Conclusion:
Nepalese medical professionals had adequate knowledge about the donated medical devices and only a few of them had practiced reusing single-use equipment. Mutual cooperation between donors and recipients is one of the most important aspects of safe medical/surgical tools delivery.

Evaluation of capacity to deliver emergency obstetrics and newborn care updated midwifery and reproductive health training curricula in Kenya: Before and after study

Introduction
Provision of emergency obstetric and newborn care (EmONC) by skilled health personnel reduces maternal and newborn mortality. Pre-service diploma midwifery and clinical medicine (reproductive health) curricula in Kenya were reviewed and updated integrating the competency based EmONC curriculum. A two-part (virtual for theoretical component and face-to-face for the skills-based component) capacity building workshop for national midwifery/clinical medicine trainers of trainers to improve their capacity to implement the updated curricula and cascade it to colleagues nationwide was conducted.

Purpose
This paper measured change in confidence of pre-service midwifery/clinical medicine educators to deliver the updated competency-based curricula in Kenya.

Methods
A before-after study among 51 midwifery/clinical medicine educators from 35 training colleges who participated in upskilling workshops as trainers-of-trainers for the updated curricula between September-November 2020. Assessment included self-reported confidence using a 3-point Likert scale (not confident, somewhat confident or extremely confident) in facilitating online teaching (as COVID-19 pandemic containment measure), EmONC skills teaching/demonstration; scenario/simulation teaching, small group discussions, peer review and giving effective feedback. Analysis involved test of proportions with p-values < 0.05 statistically significant. Results Educators’ confidence significantly improved in facilitating virtual teaching (46% to 70%, p = 0.0082). On the competency-based training, the confidence among educators significantly increased in facilitating EmONC skills teaching/demonstration (44% to 96%), facilitating scenario/simulation teaching (46% to 92%), facilitating small group discussions (46% to 94%), giving effective feedback (46% to 92%), and peer review and feedback (47% to 77%), p < 0.05). Conclusion The blended training improved the confidence of pre-service educators to deliver the updated midwifery/clinical medicine curricula.

Mobile-Social Learning for Continuing Professional Development in Low- and Middle-Income Countries: Integrative Review

Background:
Access to continuing professional development (CPD) for health care workers in low- and middle-income countries (LMICs) is severely limited. Digital technology serves as a promising platform for supporting CPD for health care workers by providing educational content virtually and enabling virtual peer-to-peer and mentor interaction for enhanced learning. Digital strategies for CPD that foster virtual interaction can increase workforce retention and bolster the health workforce in LMICs.

Objective:
The objective of this integrative review was to evaluate the evidence on which digital platforms were used to provide CPD to health care workers and clinical students in LMICs, which was complemented with virtual peer-to-peer or mentor interaction. We phrased this intersection of virtual learning and virtual interaction as mobile-social learning.

Methods:
A comprehensive database and gray literature search was conducted to identify qualitative, quantitative, and mixed methods studies, along with empirical evidence, that used digital technology to provide CPD and virtual interaction with peers or mentors. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eligible articles were written in English, conducted in an LMIC, and used a mobile device to provide CPD and facilitate virtual peer-to-peer or mentor interaction. Titles, abstracts, and full texts were screened, followed by an assessment of the quality of evidence and an appraisal of the articles. A content analysis was then used to deductively code the data into emerging themes.

Results:
A total of 750 articles were identified, and 31 (4.1%) were included in the review. SMS text messaging and mobile instant messaging were the most common methods used to provide continuing education and virtual interaction between peers and mentors (25/31, 81%). Across the included articles, participants had high acceptability for using digital platforms for learning and interaction. Virtual peer interaction and mentorship were found to contribute to positive learning outcomes in most studies (27/31, 87%) through increased knowledge sharing, knowledge gains, improved clinical skills, and improved service delivery. Peer-to-peer and mentor interaction were found to improve social support and reduce feelings of isolation (9/31, 29%). There were several challenges in the implementation and use of digital technology for mobile-social learning, including limited access to resources (eg, internet coverage and stable electricity), flexibility in scheduling to participate in CPD, and sociobehavioral challenges among students.

Conclusions:
The summary suggests that mobile-social learning is a useful modality for curriculum dissemination and skill training and that the interface of mobile and social learning serves as a catalyst for improved learning outcomes coupled with increased social capital.