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.

Genitourinary reconstructive surgery curriculum and postgraduate training program development in the Caribbean

Objectives: To describe the development of a genitourinary reconstructive fellowship curriculum and the establishment of the first genitourinary reconstructive and pelvic floor postgraduate training program in the Caribbean.

Methods: In an effort to respond to the need for specialty-trained reconstructive urologists in the Dominican Republic, we developed an18-month fellowship program to train local surgeons. The process began with creation of a curriculum and partnership with in-country physicians, societies, hospitals, and government officials. We sought accreditation via a well-established local university, and fellowship candidates were selected. A database was maintained to track outcomes. Subjective and objective reviews were performed of the fellows.

Results: The first fellow graduated in 2018, the second in 2020, and the third is currently in training. The curriculum was created and implemented. The fellowship has been successfully integrated into the health system, and the fellows performed 199 and 235 cases, respectively, during the program, completing all rotations successfully. They have been appointed to the national health system. Both graduates are now docents in the program and in the public system. Additional staff including radiologists, radiology technicians, nurses, urology residents (both Dominican and American), urology attendings, operating room staff, and anesthesia residents were trained as a result of the program.

Conclusions: To our knowledge, this is the first fellowship of its kind in the Caribbean. A novel curriculum was created and implemented, and the first 2 fellows have successfully completed all rotations. This training model may be transferable to additional sites.

Barriers and facilitators of laparoscopic surgical training in rural north-east India: a qualitative study

Introduction:
Laparoscopic surgery has advantages for treating many abdominal surgical conditions, but its use in low and middle-income countries (LMICs) is limited by many factors, including a lack of training opportunities. The aim of this study was to explore the training experiences of surgeons in rural north-east India to highlight the barriers and facilitators to laparoscopic surgery.

Methods:
Eleven surgeons with experience in laparoscopy in rural north-east India were recruited using purposive and convenience sampling. Ethical approval was obtained from the Institutional Ethics Committee, Maulana Azad Medical College, New Delhi, India and the Leeds Institute of Health Sciences Research Ethics Sub-Committee, West Yorkshire, England. Consenting participants took part in semi-structured interviews, either between May 20 and 25, 2019 in rural north-east India or via Skype or at the University of Leeds in June 2019. Interviews were audio-recorded and transcribed and thematic content analysis performed.

Results:
Exposure to laparoscopy during postgraduate training was common, but training experiences were inconsistent and informal. Alternative training opportunities are limited by availability and cost. There is high demand for a structured curriculum, incorporating formal assessment and credentialing, to include observation and assistance in live surgery and laparoscopic simulation.

Conclusions:
Laparoscopic training experiences are highly variable, with limited training resources and lack of a curriculum. Poor accessibility is consistent with that recorded in literature. Current recommendations include government support and funding to guide development of a standardized curriculum and widen access to training programs for surgeons in rural settings.

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.

The mobile surgical outreach program for management of patients with genital fistula in the Democratic Republic of Congo

Objective
To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges.

Methods
A retrospective observational study of routinely collected health data from women treated via the MSO program (2013–2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico‐surgical training, and community sensitization components.

Results
The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1–81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts.

Conclusion
The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient‐centered approach that brings medico‐surgical care and psychosocial support to women with fistula in their own communities.