Identifying knowledge needed to improve surgical care in Southern Africa using a theory of change approach.

Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: 'An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]' and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond.

Establishing a contextually appropriate laparoscopic program in resource-restricted environments: experience in Botswana.

OBJECTIVE: Differences in opinion exist as to the feasibility of establishing sustainable laparoscopic programs in resource-restricted environments. At the request of local surgeons and the Ministry of Health in Botswana, a training program was established to assist local colleagues with laparoscopic surgery. We reviewed our multifaceted and evolving international collaboration and highlighted those factors that have helped or hindered this program. METHODS: From 2006 to 2012, a training program consisting of didactic teaching, telesimulation, Fundamentals of Laparoscopic Surgery certification, yearly workshops, and ongoing mentorship was established. We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy, and measured the indicators of technical independence and program sustainability. RESULTS: Twelve surgeons participated in the training program and performed 270 of 288 laparoscopic cholecystectomies. Ninety-six open cases were performed by these and 5 additional surgeons. Fifteen laparoscopic cases were converted (5.2%). The median postoperative length of hospital stay was significantly shorter in the laparoscopic group than in the open group (1 day vs 7 days, P < 0.001). As the training program progressed, the proportion of laparoscopic cases completed without an expatriate surgeon present increased significantly (P = 0.001). CONCLUSIONS: A contextually appropriate long-term partnership may assist with laparoscopic upskilling of colleagues in low- and middle-income countries. This type of collaboration promotes local ownership and may translate into better patient outcomes associated with laparoscopic surgery. In resource-restricted environments, the factors threatening sustainability may differ from those in high-income countries and should be identified and addressed.

Designing a contextually appropriate surgical training program in low-resource settings: the Botswana experience.

BACKGROUND: The global burden of surgical disease and severe shortage of trained surgeons around the world are now widely recognized. The greatest challenge in improving access to surgical care lies in sub-Saharan Africa, where the number of surgeons per population is lowest. One part of the solution may be to create programs to train surgeons locally. We present our experience with an approach to designing a contextually appropriate surgical curriculum in Botswana. METHODS: Surgical logbooks from the largest tertiary care center in Botswana, dating from 2004 through 2010, were analyzed to yield total case numbers within clearly defined categories. Case numbers and local surgical opinion were combined to design a contextually relevant curriculum, with the Surgical Council on Resident Education curriculum as a template. RESULTS: Logbook analysis revealed that general surgeons in Botswana manage burns and perform a large number of skin grafts and extremity amputations. However, they perform few colonoscopies and complex laparoscopic procedures. The new curriculum included greater emphasis on surgical subspecialty procedures and surgical management of locally relevant conditions, such as the complications of infectious diseases. Less emphasis was placed on management of uncommon conditions such as inflammatory bowel disease. CONCLUSIONS: There are important differences in the scope of general surgery and the knowledge and skills required by general surgeons in Botswana compared with their North American counterparts. We present a simple and inexpensive approach that could serve as a potential model for designing contextually relevant surgical training programs in other low-resource settings.

Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries.

OBJECTIVES: Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study's objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa. METHODS: One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other's simulators, and communicate in real time. Learner's opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet. RESULTS: Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post-multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar's chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = -0.11 ± 1.22 [95% CI = -0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = -0.06 to 0.08 seconds]). CONCLUSIONS: Telesimulation is a novel method for teaching procedural skills. The session improved physicians' knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.