Aims There are many challenges in delivering an orthopaedic training programme in Sierra Leone, West Africa, including human resource and equipment constraints. We provide a reflective analysis of adaptive strategies to overcome these.
Methods An orthopaedic surgical training course was delivered in preparation for a clinical trial in Connaught Hospital, Freetown, Sierra Leone. The trial examines the implementation of Ilizarov frame fixation for tibia fractures in adults.
Results Whilst it is possible to deliver a high-quality course in Sierra Leone, a significant amount of prior planning and preparation, including adaptive and contingency strategies, is required to achieve the desired outcome.
Conclusions With the Royal Navy increasing its global reach, including deployment of new aircraft carriers, there are increasing opportunities to deliver medical training in low and middle-income countries in both the military and civilian sector. We believe this article may be useful for service and civilian practitioners intending to deliver education and training around the world.
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With the continued deployment of Royal Navy and Royal Marines around the world, including the Short-Term Training Teams delivering training in sub-Saharan Africa, there are a number of opportunities to deliver medical training in low and middle-income countries (LMICs). Whilst the majority of training delivered by United Kingdom (UK) Armed Forces is focused on training other military forces, there are opportunities for delivering training in a civilian hospital setting. An example is seen in the deployment of UK medical treatment facilities to countries like South Sudan.1
Many UK Defence Medical Service (DMS) secondary care personnel work in civilian National Health Service hospitals. Therefore it is possible for DMS clinicians to share their civilian and military experiences to improve the training in host countries.2 Moreover, the majority of military primary care practitioners have either trained or worked in the civilian sector, while all work following standard NHS management guidelines for common conditions. Consequently, these personnel could deliver training on many non-military subjects useful for LMIC health professionals.
There is very little information in the military literature about the difficulties and challenges of delivering teaching in the civilian LMIC setting, and what exists is limited to primarily non-surgical contexts.3 We present the challenges and adaptive process required, combined with the first reflective analysis of delivering orthopaedic training at Connaught Hospital in Freetown, Sierra Leone. These lessons can be used by service personnel who have the opportunity to deliver teaching in other LMIC settings.
In 2017 the National Institute for Health Research (NIHR) funded a Global Health Research Programme, and the University of Leeds became the hub of the Global Surgical Technologies Research Group.4 The group aims to develop and evaluate surgical technologies to benefit patients in Sierra Leone and rural India.5 In Sierra Leone the group is running a single centre clinical trial (the FIXT trial) to evaluate the feasibility, safety and cost-effectiveness of Ilizarov frame fixation versus conservative management for closed tibial fractures in adults (trial registration numbers: ISRCTN51545197; PACTR201901523303171). The trial has a before and after non-randomised implementation design with an in-built process and health economics evaluation. A total of 40 patients will be recruited consecutively; the first 20 will receive conservative management involving plaster of Paris plus or minus skin traction, and the second 20 will receive operative fixation with the Ilizarov frame. In order to ensure that the intervention is implemented safely and effectively in a standardised manner, a frame care training course was delivered. This consisted of a combination of lectures covering the mechanics of the Ilizarov frame, clinical indications, operative deployment, complications, physiotherapy and follow-up care. To complement this, a series of hands-on practical training sessions on the frame construction, pin site care and physiotherapy were conducted.
The trial is based at Connaught Hospital in Freetown, the capital city of Sierra Leone, which serves as the main government reference hospital for the entire country. Sierra Leone is a West African country with a population of approximately 7 million and a severely constrained surgical health system.6 The hospital has 300 beds of which 108 are surgical (76 adult and 32 paediatric). It has five functional operating theatres and only one fully trained orthopaedic surgeon who has previous experience of Ilizarov frame limb-sparing reconstructive surgery for closed tibial fractures. It has four post-graduate surgical trainees and is the teaching hospital for the University of Sierra Leone and the College of Medicine and Allied Health Sciences (COMAHS).
The results are presented in a structure designed to provide a meaningful narrative account of the authors’ experiences and reflections.
Prior to deploying it was important to identify the following areas:
Where are the hospitals and what are the needs of the hospital?
There is a relative paucity of epidemiological data concerning medical and surgical requirements for trauma care in Sierra Leone, and while there have been recent attempts to investigate trauma workload, the information is limited compared to contemporary UK literature.7–9 The recent Ebola outbreak has led to an increased awareness in the western literature about the situation in Sierra Leone, but much of this gives a snapshot about one significant event, with limited information about the other general requirements.6,9,10 Further research is needed to provide granular data on the epidemiology and patient outcomes of injury and trauma care, in order to inform health system readiness assessments and the future planning of surgical and system interventions for the improvement of care.
In order to identify the requirements, making contact early and having detailed discussions with local partners is essential. Co-developing training interventions with local LMIC partners improves the effectiveness, relevance and sustainability. Sierra Leone has different levels of hospitals, each with different requirements. In Freetown there are hospitals supported directly by other countries, such as the Italian non-governmental organisation (NGO) hospital EMERGENCY. These hospitals have much high-income country (HIC) support and to have another HIC team delivering teaching specifically at these sites would be of limited value. There are also private hospitals, still fairly limited, and only a small number of select patients can access this sector. As a result, they do not present optimal opportunities for teaching. The Government public hospitals are often poorly resourced, with massive health education requirements. Although Connaught Hospital is the main teaching hospital, resources can be constrained and it is essential to understand what the visiting team needs to supply (Figures 1–3).
Having identified the hospital and local partners, it is important to know what the training requirements and existing abilities are. Through our discussions with surgeons at Connaught, we were able to identify that although our principle contact was able to manage tibial fractures surgically, his team had very limited training in the surgical management of tibial fractures and he had limited resources. As part of the trial, it was important to deliver a training programme to teach nurses, physiotherapists, anaesthetists and surgeons about the management of tibial fractures using the Ilizarov technique. This includes multiple aspects of the patient journey, through the initial surgery, ward level care, follow-up and physiotherapy to ensure complications are managed appropriately and that the best functional outcome possible is achieved.
Satisfying the identified requirements
Having identified an area of need, we needed to identify how we were going to deliver the training. In the FIXT trial it was important to ensure that we covered all of the aspects required to deliver Ilizarov surgery and after care in Connaught Hospital.
Resource considerations in Sierra Leone
In this phase it is important to identify your target audience and what their requirements will be. In Connaught Hospital, there were general surgeons and a large number of nurses attending as well as orthopaedic surgeons and trainee doctors. This was in contrast to a UK course where the majority of attendees will be doctors. As a result, it was important to tailor the course accordingly. Some of the more complicated lectures required more explanation and more time, while other lectures were not relevant to a developing country. As a result, having used the UK course as a template, we were able to remove some lectures and add others. It is important to take detailed notes, as it should not be assumed that all or any equipment will be available locally.
Provision of educational packs
Unlike UK courses where most literature is given in electronic form, it is important to produce enough paper packs for all the attendees. In our case we delivered lectures to 45 people, despite being told that 25 people would be in attendance. There is an expectation that everyone attending will have a literature pack, and there was no local way to produce these in time, so they needed to be prepared prior to the course. We would recommend producing around 50% more packs than you expect people to attend, as often extra participants will attend upon hearing of a visiting training course.
Prepare to be flexible, even with months of planning; a two-day course can quickly become two 1½ day courses, as happened in our case due to the necessities of service provision.
When delivering lecture material, it is important to cover all modalities of the computer/projector interface. Due to the number of different computer types and connections, all instructors should bring their own connectors, or the course facilitator should bring a selection. In our case there was no projector available locally and therefore a projector was brought with the team to facilitate the training. Identify who should be giving lectures and where extra training is required to fill any knowledge gaps before you get there. In our case, most of the instructors had completed a civilian instructor training course such as the Advanced Trauma Life Support instructor course. It is easy to underestimate how intimidating delivering lectures in a different country can be, and provision of an appropriate tool kit before attending can help the junior instructors mentally prepare for the course. They may be confident teaching their peers in a UK setting, but the difficulties and unfamiliar environment can lead to increased stress; good preparation of the instructors help to reduce this.
During the training, we needed to give the nurses physiotherapy advice and teaching. None of the instructors were physiotherapists, but this training need was identified, and one of our clinical lecturers was able to attend physio teaching and obtain the necessary advice and instruction for him to deliver this training serial. This educational limitation was established by going through the programme with a fine-toothed comb with enough time to identify and sort any educational requirements.
A very different environment
Be prepared for behaviour in lectures that you would not normally expect in the UK, or for unsolicited input into the lectures, and brief the team accordingly. It is frequent for the more senior medical staff to intervene and impart their knowledge in the middle of a lecture, and this may contradict the advice just given. It is important to ensure that co-creation and co-delivery by visitors and local trainers makes the material delivered context-specific, taking into consideration cultural and technical differences. Being sensitive to these will ensure a good rapport between visitors and local teams. In our case, the majority of the clinical staff who attended the training were still on call for their clinical duties, and at times they had to leave to attend to these.
Expect that some of your advice may not be compatible with the local situation. We made every effort to tailor our lectures according to the facilities and education of our attendees, but at times we got things wrong. This could be something as simple as suggesting where a scrub nurse should be to optimise the theatre dynamics, not being aware that this location is not possible when operating on the opposite leg in their theatre because the only power point is on another wall. In order to manage these limitations, when giving advice or instruction, we found it useful to warn that we were giving suggestions and discussing how things work best in our practice, but that there might be reasons which we were unaware of why others could not deliver these outputs.
Expect timings to slip and be prepared for a leisurely start to events. During our courses, we had one day where it was impossible to travel to the hospital, because of the monthly cleaning morning, where the whole area is cleaned at once, preventing movement around the city.
We made a conscious effort to deliver a one-day course over two days when we set out, because we were uncertain of the training level and how much explanation would be required. As it happened, we were grateful for the extra capacity the course gave us due to logistical problems; leaving room for manoeuvre on the course will reduce frustration and allow objectives to be achieved.
Lecturers should be kept hydrated, comfortable and safe. Whilst in the UK we may lecture in suits or formal attire, it is important to think of the environment. It may not be appropriate to attend a civilian hospital in uniform; therefore, briefing your lecturers that it is acceptable to lecture in shorts and shirts or female equivalent may make the whole process more rewarding for everyone. You should expect that there will be limited or no air-conditioning. JSP 539 gives good advice on managing heat stress, and it is important to identify this as an issue which you will not normally encounter in the UK.11
As with UK courses, it is important to ascertain if the course met its objectives. We did this in two ways, with verbal feedback in the final session and also formal written feedback. The course was well received and the feedback was that the educational needs were exceeded during the course. We were humbled by the verbal feedback and how appreciative the attendees were. On our course, participants particularly valued the hands-on simulation training, which they had never experienced before in such detail, but they found an eight-hour day a long time to maintain their attention in the heat.
There are increasing opportunities to impart medical knowledge and undertake training in both the civilian and military sectors. We have demonstrated that it is possible to deliver advanced medical education in Sierra Leone, but that it is important to acknowledge that a number of considerations should be considered to ensure an effective course delivery. We hope that the information contained in this article is useful for personnel delivering similar training in the future.
Conflicts of interest
The authors declare no conflicts of interest.
This research was funded by the National Institute for Health Research (NIHR) (16/137/44) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care.
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