Prof. Abebe Bekele

Background: Increasing surgical specialist workforce density in sub‐ Saharan Africa is essential for improving access to surgical care. However, out‐migration creates a significant challenge to attaining provider targets. We aimed to determine the rates and trends of retention of surgeons in the College of Surgeons of East Central and Southern Africa (COSECSA) regions. Methodology: An online, web‐based survey was distributed to COSECSA surgeons who graduated from 2004 to 2020. Current practice and migration patterns were visualized using descriptive analyses and logistic regression models. Results: Response rate was 48% (270/557). Most respondents trained as general surgeons and practiced in Ethiopia, Kenya, Zimbabwe, and Zambia. Majority practiced in public hospitals (74%), and were active in research (81%), teaching (84%) and leadership (55%). Overall country (85%), regional (92%) and Africa retention rates (99%) were high with 100% country retention in Rwanda, Botswana, Lesotho, and Namibia. Tanzania had the lowest retention (61%). Highest inter‐regional migration occurred from East to Southern Africa (26%), and continental out‐migration occurred from Zambia, Zimbabwe, and Kenya. On bivariate analysis, out‐migration from training country and region was associated working with a non‐ governmental organization (p = 0.002 and 0.0003) or a specialized hospital (p = 0.046 and 0.011). A multiple regression model with type of institution and leadership was a poor fit (McFadden R2 = 0.055; p = 0.082). Conclusion: Retention rates of surgeons trained by COSECSA in the region remain remarkably high. This can be taken as an indicator of success of the training model to increase surgical workforce density, however, contributory factors need to be qualitatively explored.

AbstractBackgroundIncreasing surgical specialist workforce density in sub‐Saharan Africa is essential for improving access to surgical care. However, out‐migration creates a significant challenge to attaining provider targets. We aimed to determine the rates and trends of retention of surgeons in the College of Surgeons of East Central and Southern Africa (COSECSA) regions.MethodologyAn online, web‐based survey was distributed to COSECSA surgeons who graduated from 2004 to 2020. Current practice and migration patterns were visualized using descriptive analyses and logistic regression models.ResultsResponse rate was 48% (270/557). Most respondents trained as general surgeons and practiced in Ethiopia, Kenya, Zimbabwe, and Zambia. Majority practiced in public hospitals (74%), and were active in research (81%), teaching (84%) and leadership (55%). Overall country (85%), regional (92%) and Africa retention rates (99%) were high with 100% country retention in Rwanda, Botswana, Lesotho, and Namibia. Tanzania had the lowest retention (61%). Highest inter‐regional migration occurred from East to Southern Africa (26%), and continental out‐migration occurred from Zambia, Zimbabwe, and Kenya. On bivariate analysis, out‐migration from training country and region was associated working with a non‐governmental organization (p = 0.002 and 0.0003) or a specialized hospital (p = 0.046 and 0.011). A multiple regression model with type of institution and leadership was a poor fit (McFadden R2 = 0.055; p = 0.082).ConclusionRetention rates of surgeons trained by COSECSA in the region remain remarkably high. This can be taken as an indicator of success of the training model to increase surgical workforce density, however, contributory factors need to be qualitatively explored.

AbstractMuch innovation has taken place in the development of medical schools and licensure exam processes across the African continent. Still, little attention has been paid to education that enables the multidisciplinary, critical thinking needed to understand and help shape the larger social systems in which health care is delivered. Although more than half of medical schools in Canada, the United Kingdom, and the United States offer at least one medical humanities course, this is less common in Africa. We report on the “liberal arts approach” to medical curricula undertaken by the University of Global Health Equity beginning in 2019. The first six-month semester of the curriculum, called Foundations in Social Medicine, includes courses in critical thinking and communication, African history and global political economy, medical anthropology and social medicine, psychology and health, gender and social justice, information technology and health, and community-based training. Additionally, an inquiry-based pedagogy with relatively small classes is featured within an overall institutional culture that emphasizes health equity. We identify key competencies for physicians interested in pursuing global health equity and how such competencies relate to liberal arts integration into the African medical school curriculum and pedagogical approach. We conclude with a call for a research agenda that can better evaluate the impact of such innovations on physicians’ education and subsequent practices.

Background: This article presents a qualitative study of African anatomists and anatomy teachers on the Anatomage Table–a modern medical education technology and innovation, as an indicator of African anatomy medical and anatomy educators’ acceptance of EdTech. The Anatomage Table is used for digital dissection, prosection, functional anatomy demonstration, virtual simulation of certain functions, and interactive digital teaching aid. Materials and Methods: Anatomy teachers [n=79] from 11 representative African countries, Ghana, Nigeria [West Africa], Ethiopia, Kenya, Rwanda [East Africa], Namibia [South Africa], Zambia [Southern Africa], Egypt [North Africa], and Sudan [Central Africa], participated in this study. Focus group discussions [FGDs] were set up to obtain qualitative information from stakeholders from representative institutions. In addition, based on the set criteria, selected education leaders and stakeholders in representative institutions participated in In-depth Interviews [IDIs]. The interview explored critical issues concerning their perceptions about the acceptance, adoption, and integration of educational technology, specifically, the Anatomage Table into the teaching of Anatomy and related medical sciences in the African continent. Recorded interviews were transcribed and analyzed using the Dedoose software. Results: African anatomists are generally technology inclined and in favor of EdTech. The most recurring opinion was that the Anatomage Table could only be a “complementary teaching tool to cadavers” and that it “can’t replace the real-life experience of cadavers.” Particularly, respondents from user institutions opined that it “complements the traditional cadaver-based approaches” to anatomy learning and inquiry, including being a good “complement for cadaveric skill lab” sessions. Compared with the traditional cadaveric dissections a majority also considered it less problematic regarding cultural acceptability and health and safety-related concerns. The lifelikeness of the 3D representation is a major factor that drives acceptability. Keywords: anatomy, Anatomage, educational technology, medical education, innovations, Africa.

Background Medical educators have underscored the need for medical students to study the larger sociocultural and economic forces that influence health rather than simply basic and clinical sciences; however, previous studies have not evaluated the impact of implementing a full-scale liberal arts approach to medical education. Such a model has been implemented at the University of Global Health Equity (UGHE) in Rwanda, and we sought to evaluate the student experience. Methods We used a qualitative study with a grounded theory approach with in-depth interviews of MBBS students at UGHE. Interviews were conducted by members of the researcher team unknown to MBBS students using a semi-structured discussion guide; interviews continued until the point of theoretical saturation, and we used the constant comparison method of qualitative data analysis to understand recurrent themes. Results Participants (n = 18) were evenly split between male and female; 66.7% were from Rwanda and 33.3% were international students. Participants had completed the liberal arts component of the curriculum, which was given in the first 6 months of the MBBS. Recurrent themes emerged in four broad areas pertaining to what the liberal arts approach was and its impact on students, their peer groups, and their perceived clinical capability. The four recurrent themes were: (1) the liberal arts experience encompassed a unique approach to class content, pedagogy, and culture, (2) it widened student perspectives, (3) it strengthened peer relations and teamwork skills, and (4) students believed it improved their clinical capability. Conclusions Medical students reported a profound effect of including a liberal arts approach in the medical undergraduate curriculum as delivered at UGHE. With increased accessibility to online education, it has never been more important to examine and support the humanization of education–particularly for medical students who wish to tackle global health equity. A liberal arts approach may offer a path forward.

Background Clinical practitioners are influential figures in the public’s health-seeking behavior. Therefore, understanding their attitudes toward the COVID-19 vaccine is critical for implementing successful vaccination programs. Our study aimed to investigate clinical practitioners’ acceptance of the COVID-19 vaccine and associated factors for evidence-based interventions. Methods Data from 461 clinical practitioners were collected using a cross-sectional design via an online self-administered survey. Descriptive and multiple logistic regression analyses and chi-square tests were conducted using R version 3.6.1. Results The COVID-19 vaccine was accepted by 84.4 percent of those polled, and 86.1 percent said they would recommend it to others. Individuals with advanced levels of education demonstrated greater readiness for vaccine acceptance (P<0.001) and willingness to recommend (P<0.001). On the other hand, practitioners with concerns about the safety of vaccines developed in emergency settings were less likely to accept vaccines (OR = 0.22). Practitioners influenced by social media posts (OR = 0.91) and religious beliefs (OR = 0.71) were found to be less willing to recommend the vaccine. Conclusion The study demonstrated that interventions to improve clinical practitioners’ acceptance and recommendation of the COVID-19 vaccine should consider the following factors: level of experience and education, religious beliefs, safety concerns, specific profession, and source of information. Vaccine literacy efforts that directly address specific concerns and misconceptions, such as those that reconcile social media information and religious beliefs with scientific literature, are recommended.

Background: To address the global need for accessible evidence-based tools for competency-based education, we developed ENTRUST, an innovative online virtual patient simulation platform to author and securely deploy case scenarios to assess surgical decision-making competence. Study Design: In partnership with COSECSA, ENTRUST was piloted during the Membership of the College of Surgeons (MCS) 2021 examination. Examinees (n=110) completed the traditional 11-station oral OSCE, followed by three ENTRUST cases, authored to query similar clinical content of three corresponding OSCE cases. ENTRUST scores were analyzed for associations with MCS Exam outcome using independent sample t-tests. Correlation of ENTRUST scores to MCS Exam Percentage and OSCE Station Scores were calculated with Pearson correlations. Bivariate and multivariate analyses were performed to evaluate predictors of performance. Results: ENTRUST performance was significantly higher in examinees who passed the MCS Exam compared to those who failed (p<0.001). ENTRUST score was positively correlated with MCS Exam Percentage (p<0.001) and combined OSCE Station Scores (p<0.001). On multivariate analysis, there was a strong association between MCS Exam Percentage and ENTRUST Grand Total Score (p<0.001), Simulation Total Score (p=0.018), and Question Total Score (p<0.001). Age was a negative predictor for ENTRUST Grand Total and Simulation Total Score, but not for Question Total Score. Sex, native language status, and intended specialty were not associated with performance on ENTRUST. Conclusion: This study demonstrates feasibility and initial validity evidence for the use of ENTRUST in a high-stakes examination context for assessment of surgical decision-making. ENTRUST holds potential as an accessible learning and assessment platform for surgical trainees worldwide.

Background : Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods: Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results : Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions: A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula. Keywords: consensus; delphi; medical school; rwanda; surgery curriculum.

Since the first African country attained independence from colonial rule, surgical training on the continent has evolved along 3 principal models. The first is a colonial, local master-apprentice model, the second is a purely local training model, and the third is a collegiate intercountry model. The 3 models exist currently and there are varied perceptions of their relative merits in training competent neurosurgeons. We reviewed the historical development of training and in an accompanying study, seek to describe the complex array of surgical training pathways and explore the neocolonial underpinnings of how these various models of training impact today the development of surgical capacity in Africa. In addition, we sought to better understand how some training systems may contribute to the widely recognized “brain drain” of surgeons from the African continent to high income countries in Europe and North America. To date, there are no published studies evaluating the impact of surgical training systems on skilled workforce emigration out of Africa. This review aims to discover potentially addressable sources of improving healthcare and training equity in this region.

Background As a result of gradual independence from colonial rule over the course of the past century, Africa has developed and evolved 3 primary surgical training structures: an extracontinental colonial model, an intracontinental college-based model, and several smaller national or local models. There is consistent evidence of international brain drain of surgical trainees and an unequal continental distribution of surgeons; however there has not, to date, been an evaluation of the impact colonialism on the evolution of surgical training on the continent. This study aims to identify the etiologies and consequences of this segmentation of surgical training in Africa. Methods This is a cross-sectional survey of the experience and perspectives of surgical training by current African trainees and graduates. Results A surgeon's region of residence was found to have a statistically significant positive association with that of a surgeon's training structure (P <0.001). A surgeon's professional college or structure of residency has a significantly positive association with desire to complete subspecialty training (P = 0.008). College and structure of residency also are statistically significantly associated with successful completion of subspecialty training (P < 0.001). Conclusions These findings provide evidence to support the concept that the segmentation of surgical training structures in Africa, which is the direct result of prior colonization, has affected the distribution of trainees and specialists across the continent and the globe. This maldistribution of African surgical trainees directly impacts patient care, as the surgeon–patient ratios in many African countries are insufficient. These inequities should be acknowledged addressed and rectified to ensure that patients in Africa receive timely and appropriate surgical care.