Bioethical challenges in postwar development aid: The Rwandan case study.

This article considers aspects of a development aid that provides medical support to strengthen pediatric orthopedics in Rwanda. We present part of the Afriquia foundation work, a nonprofit foundation from Poland involved in supporting the medical sector in Rwanda as a sign of global solidarity and the human right to health. The main foundation's activity is the treatment of orthopedic problems among Rwandan citizens. We present a case study of two children under the care of the Afiquia foundation. 11-year-old Seraphine treated due to the consequences of right tibia osteomyelitis and 11-year-old Lavi suffering from osteogenesis imperfecta. Both children were treated surgically in Poland due to Rwanda's lack of treatment possibilities. After the applied treatment, Seraphine walks correctly without crutches and can attend school and thrive among her peers. Lavi has not sustained any fragility fracture since the surgery in Poland. He is healthy and constantly ongoing his rehabilitation including gait training. The described cases initiated development aid in Rwanda, supplying hospitals with orthopedic implants and training medical staff. The growing number of humanitarian crises across the globe and the people affected requires increasing organizations involved in providing relief. The emphasis should be on global education, aiming to make the recipients reflect and prepare them to face humanitarian crises.

Gender-based analysis of factors affecting junior medical students' career selection: addressing the shortage of surgical workforce in Rwanda.

BACKGROUND: There is a strong need for expanding surgical workforce in low- and middle-income countries. However, the number of medical students selecting surgical careers is not sufficient to meet this need. In Rwanda, there is an additional gender gap in speciality selection. Our study aims to understand the early variables involved in junior medical students' preference of specialisation with a focus on gender disparities. METHODS: We performed a cross-sectional survey of medical students during their clinical rotation years at the University of Rwanda. Demographics, specialisation preference, and factors involved in that preference were obtained using questionnaires and analysed using descriptive statistics and odds ratios. RESULTS: One hundred eighty-one respondents participated in the study (49.2% response rate) with a female-to-male ratio of 1 to 2.5. Surgery was the preferred speciality for 46.9% of male participants, and obstetrics/gynaecology for 29.4% of females. The main selection criteria for those who had already decided on surgery as a career included intellectual challenge (60.0%), interaction with residents (52.7%), and core clerkship experience (41.8%) for male participants and interaction with residents (57.1%), intellectual challenge (52.4%), and core clerkship experience (52.4%) for female participants. Females were more likely than males to join surgery based on perceived research opportunities (OR 2.7, p = 0.04). Male participants were more likely than their female participants to drop selection of surgery as a speciality when an adverse interaction with a resident was encountered (OR 0.26, p = 0.03). CONCLUSION: This study provides insight into factors that guide Rwandan junior medical students' speciality preference. Medical students are more likely to consider surgical careers when exposed to positive clerkship experiences that provide intellectual challenges, as well as focused mentorship that facilitates effective research opportunities. Ultimately, creating a comprehensive curriculum that supports students' preferences may help encourage their selection of surgical careers.

A qualitative study on perceptions of surgical careers in Rwanda: A gender-based approach.

Access to surgical care in low- and middle-income countries (LMICs) remains deficient without an adequate workforce. There is limited understanding of the gender gap in surgical trainees in LMICs. In Rwanda, females fill only one of 20 positions available. Understanding surgeons' experiences and perceptions of surgical careers may help facilitate support for females to contribute to the global surgical workforce. We performed qualitative analysis on perceptions of surgical careers through semi-structured interviews of all female surgeons (n = 6) and corresponding male surgeons (n = 6) who are training or have trained at University of Rwanda. Transcripts were analyzed with code structure formed through an integrated approach. Question categories formed the deductive framework, while theoretical saturation was reached through inductive grounded theory. Themes were organized within two key points of the career timeline. First, for developing interest in surgery, three main themes were identified: role models, patient case encounters, and exposure to surgery. Second, for selecting and sustaining surgical careers, four main themes emerged: social expectations about roles within the family, physical and mental challenges, professional and personal support, and finances. All female surgeons emphasized gender assumptions and surgical working culture as obstacles, with a corresponding strong sense of self-confidence and internal motivation that drew them to select and maintain careers in surgery. Family, time, and physical endurance were cited as persistent challenges for female participants. Our study reveals concepts for further exploration about gendered perceptions of surgical careers. Efforts to improve support for female surgical careers as a strategy for shaping surgical work culture and professional development in Rwanda should be considered. Such strategies may be beneficial for improving the global surgical workforce.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District.

IMPORTANCE: In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning. OBJECTIVE: To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined. MAIN OUTCOMES AND MEASURES: The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design. RESULTS: Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital. CONCLUSIONS AND RELEVANCE: The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.

Validation of a community-based survey assessing nonobstetric surgical conditions in Burera District, Rwanda.

BACKGROUND: Validated, community-based surveillance methods to monitor epidemiologic progress in surgery have not yet been employed for surgical capacity building. The goal of this study was to create and assess the validity of a community-based questionnaire collecting data on untreated surgically correctable disease throughout Burera District, Rwanda, to accurately plan for surgical services at a district hospital. METHODS: A structured interview to assess for 10 index surgically treatable conditions was created and underwent local focus group and pilot testing. Using a 2-stage cluster sampling design, Rwandan data collectors conducted the structured interview in 30 villages throughout the Burera District. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. RESULTS: A total of 2,990 individuals were surveyed and 2,094 (70%) were available for physical examination. The calculated sensitivity and specificity of the survey tool were 44.5% (95% CI, 38.9-50.2%) and 97.7% (95% CI, 96.9-98.3%), respectively. The conditions with the highest sensitivity and specificity were hydrocephalus, clubfoot, and injuries/infections. Injuries/infections and hernias/hydroceles were the conditions most frequently found on examination that were not reported during the interview. CONCLUSION: This study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity was likely related to limited access to care and poor health literacy. Accurate community-based surveys are critical to planning integrated health systems that include surgical care as a core component.

Validation of a community-based survey assessing non-obstetric surgical conditions in Burera District, Rwanda.

BACKGROUND: Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The aim of this study was to create and assess the validity of a questionnaire that collected data for untreated surgically correctable diseases throughout Burera District, northern Rwanda, to accurately plan for surgical services. METHODS: A structured interview to assess for the presence or absence of ten index surgically treatable conditions (breast mass, cleft lip/palate, club foot, hernia or hydrocele [adult and paediatric]), hydrocephalus, hypospadias, injuries or wounds, neck mass, undescended testes, and vaginal fistula) was created. The interview was built based on previously validated questionnaires, forward and back translated into the local language and underwent focus group augmentation and pilot testing. In March and May, 2012, data collectors conducted the structured interviews with a household representative in 30 villages throughout Burera District, selected using a two-stage cluster sampling design. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all households. FINDINGS: 2990 individuals were surveyed, a 97% response rate. 2094 (70%) individuals were available for physical examination. The calculated overall sensitivity of the structured interview tool was 44·5% (95% CI 38·9-50·2) and the specificity was 97·7% (96·9-98·3%; appendix). The positive predictive value was 70% (95% CI 60·5-73·5), whereas the negative predictive value was 91·3% (90·0-92·5). The conditions with the highest sensitivity and specificity, respectively, were hydrocephalus (100% and 100%), clubfoot (100% and 99·8%), injuries or wounds (54·7% and 98·9%), and hypospadias (50% and 100%). Injuries or wounds and hernias or hydroceles were the conditions most frequently identified on examination that were not reported during the interview (appendix). INTERPRETATION: To the best of our knowledge, this study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity limits the use of the tool, which will require further revision, and calls into question previously published unvalidated community surgical survey data. To improve validation of community-based surveys, community education efforts on common surgically treatable conditions are needed in conjunction with increased access to surgical care. Accurate community-based surveys are crucial to integrated health system planning that includes surgical care as a core component. FUNDING: The Harvard Sheldon Traveling Fellowship.

Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey.

BACKGROUND: In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. METHODS: In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FINDINGS: Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). INTERPRETATION: Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FUNDING: The Harvard Sheldon Traveling Fellowship.

Biomechanical and safety testing of a simplified negative-pressure wound therapy device.

BACKGROUND: There is a large, unmet need for acute and chronic wound care worldwide. Application of proven therapies such as negative-pressure wound therapy in resource-constrained settings is limited by cost and lack of electrical supply. To provide an alternative to existing electrically powered negative-pressure wound therapy systems, a bellows-powered negative-pressure wound therapy system was designed and iteratively improved during field-based testing. The authors describe the design process and the results of safety and biomechanical testing of their simplified negative-pressure wound therapy system. METHODS: Simplified negative-pressure wound therapy was tested at two hospitals in Rwanda. Patients with wounds ranging from 2 to 150 cm and meeting inclusion and exclusion criteria were enrolled. Wounds were categorized by difficulty of dressing application according to location and contour. Outcomes were maintenance of negative pressure and occurrence of adverse events. RESULTS: Thirty-seven patients with 42 wounds were treated with simplified negative-pressure wound therapy. Eighty-five dressings in total were applied. On average, the final simplified negative-pressure wound therapy dressing maintained negative pressure for 31.7 hours on all wounds (n = 37), and 52.7 hours on wounds in easy-to-dress locations. No unexpected adverse events occurred. CONCLUSIONS: This is the first systematic report of the performance of a bellows-powered negative-pressure wound therapy device designed specifically for use in resource-constrained settings. The authors found that elimination of air leaks in the simplified negative-pressure wound therapy dressing is essential, and that their system is safe and feasible for use in these environments. Subsequent trials will study the system's efficacy.