Damir Ljuhar

Evaluation is a vital part of any learning activity and is essential to optimize and improve educational programmes. It should be considered and prioritized prior to the implementation of any learning activity. However, comprehensive programme evaluation is rarely conducted, and there are numerous barriers to high‐quality evaluation. This review provides a framework for conducting outcome evaluation of simulation‐based education programmes in low and middle‐income countries (LMICs). The basis of evaluation, including core ideas of theory, purpose and structure are outlined, followed by an examination of the levels and healthcare applications of the Kirkpatrick model of evaluation. Then, methods of conducting evaluation of simulation‐based education in LMICs are discussed through the lens of a successful surgical simulation programme in Myanmar, a lower‐middle‐income country. The programme involved the evaluation of 11 courses over 4 years in Myanmar and demonstrated evaluation at the highest level of the Kirkpatrick model. Reviewing this programme provides a bridge between evaluation theory and practical implementation. A range of evaluation methods are outlined, including surveys, interviews, and clinical outcome measurement. The importance of a mixed‐methods approach, enabling triangulation of quantitative and qualitative analysis, is highlighted, as are methods of analysing data, including statistical and thematic analysis. Finally, issues and challenges of conducting evaluation are considered, as well as strategies to overcome these barriers. Ultimately, this review informs readers about evaluation theory and methods, grounded in a practical application, to enable other educators in low‐resource settings to evaluate their own activities.

Introduction: Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low‐ and Middle‐Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation‐based education (SBE), the Air Enema (AE) non‐operative technique was introduced in 2016 in Myanmar. This study assesses the long‐term outcomes.Methods: Mixed methods study design over 4 years including clinical outcomes and surgeon's attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi‐structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long‐term shift to non‐operative intervention. Secondary outcomes: Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann–Whitney U test, Fisher's exact test, Student's T‐Test or Wilcoxon Signed‐Rank Test utilised. A p‐value of <.05 was considered significant.Results: A total of 311 infants with intussusception were included. A sustained shift to AE was revealed with high success rates (86.1–91.2%). AE had a reduced LoS (4 vs. 7 days p ≤ 0.0001), Duration of Symptoms (DoS) was lower with AE (1.9/7 vs. 2.5/7, p = 0.002). Low recurrence rates (0–5.8%) and intestinal resection rates stabilised at 30.5–31.8% vs.15.3% pre‐intervention. Four RTA themes were identified: Expanding conceptions of healthcare professional education and training; realising far reaching advantages; promoting critical analysis and reflective practice of clinicians; and adapting clinical practice to local context. RTA revealed an overall positive paradigm shift in attitudes and application of SBE.Conclusions: A sustained change in clinical outcomes and appreciation of the value of SBE was demonstrated following the intervention.

Purpose To define the spectrum of management for thoracic empyema in children in Australia and New Zealand. Methods Online survey of members of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS), limited to consultant/attending paediatric surgeons. Results A total of 54/80 (67.5%) members, from 16 paediatric surgical centres, responded. The majority (33/54, 61%) preferred chest drain with fibrinolytics, whilst 21/54 (39%) preferred video-assisted thoracoscopic surgery (VATS) with drain insertion. Urokinase was the most commonly used fibrinolytic (64%). There were no significant differences in management preferences between practising surgeons in Australia and New Zealand (p = 0.54), nor between consultants who had been practising a shorter (< 5 years) or longer (> 20 years) amount of time (p = 0.21). The practices described by the surveyed ANZAPS members were in line with the Thoracic Society of Australia and New Zealand recommendations for the management of paediatric empyema. Conclusion Across Australia and New Zealand there exists significant variation surrounding the intra- and post-intervention management of thoracic empyema in children. The surveyed paediatric surgeons demonstrated a preference for fibrinolytics over the use of VATS. All management regimens were within published local guidelines.

Background: Simulation‐based medical education (SBME) is an integral part of undergraduate and postgraduate training in high‐income countries (HICs). Despite potential benefits to low‐ and middle‐income countries (LMICs), it has not been widely applied. Our aim was to use SBME to address some essential paediatric surgery learning needs in a LMIC.Methods: Eleven SBME courses were designed, implemented and evaluated over a 4‐year period in partnership with local paediatric surgeons and the University of Medicine 1 in Yangon, Myanmar. All courses were simulation‐based and different major SBME modalities were utilized. Evaluation included pre‐ and post‐course questionnaires, other evaluation assessments including Likert scale self‐rated confidence in different domains, as well as, mixed method evaluation and Kirkpatrick's hierarchy of evaluation.Results: Over 4 years, a multidisciplinary team consisting of surgical consultants, fellows, and educational specialists delivered 11 courses at a tertiary LMIC paediatric surgical centre. Attendance varied between 23 and 50 healthcare professionals, with some participants attending all of the educational activities. SBME modalities were utilized to meet each courses' learning objectives. All educational courses scored highly and showed statistically significant differences in all the self‐rated pre and post‐course confidence Likert scale domains. SBME was accepted and embraced by local participants and faculty, and transition to local delivery of educational content has begun. Level 4 of Kirkpatrick's hierarchy of evaluation was demonstrated.Conclusion: SBME can be used to meet essential learning objectives of local staff in a LMIC. Through various modalities, it offers a reliable, proven and affordable means of teaching multiple aspects of paediatric surgical clinical practice. By employing innovative simulation‐based solutions, it can be adapted by local faculty to continue meeting ongoing learning needs.

Circumcision is one of the most commonly performed surgical procedures in the world. Despite this, the practice of paediatric circumcision remains highly controversial, and continues to generate ongoing debate. This debate has become more relevant recently with the provisional guidelines from the Centers for Disease Control and Prevention recommending a change of practice. In this review article, we provide an overview of the history and incidence of circumcision, normal preputial development, types of phimosis, the absolute and relative indications for circumcision as well as the evidence base for its use as a preventative measure. Our aim is to provide paediatricians with a greater understanding of this common surgical procedure and the conditions it treats, to guide their clinical practice and parent counselling.