Sarah Nuss

Hearing loss is a major global health concern, yet many countries lack the necessary workforce to provide hearing care services. This study aimed to evaluate the global distribution, availability, and training of hearing healthcare providers, including audiologists and other professionals involved in hearing care. A cross-sectional electronic survey was conducted from June 2022 to March 2024 by the Global Otolaryngology-Head and Neck Surgery Initiative, collecting national-level data from 93 countries representing 77 percent of the world's population. Responses were analysed by income classification and geographic region based on World Bank and World Health Organization categories. The global density of audiologists was 1.48 per 100,000 people, with more than 70 percent of countries reporting fewer than one audiologist per 100,000. The overall hearing healthcare workforce density was 4.1 per 100,000 population. Training opportunities were limited in low-income countries, where 83 percent of audiologists were trained outside their home country. The African, Eastern Mediterranean, and South-East Asian regions were especially underserved. Workforce roles and service scope varied widely across regions and income levels. These findings highlight critical disparities and emphasise the need for targeted workforce planning and sustainable training programs to improve global hearing care.

Background: Mobile health (mHealth) apps are increasingly leveraged to support community health workers (CHWs) in delivering high-quality care, particularly in low- and middle-income countries. However, despite the proliferation of mHealth tools, few have been implemented at scale, partly due to limited attention to usability and acceptability among end users. In sub-Saharan Africa, mHealth tools designed for CHWs often lack systematic evaluation using validated instruments tailored to local contexts. Without such assessments, it is difficult to ensure that these tools can be integrated effectively into CHW workflows and scaled sustainably. Objective: This study aimed to adapt and validate existing mHealth usability and acceptability assessment tools to be contextually appropriate for CHWs in Rwanda. Specifically, we sought to ensure contextual appropriateness for CHWs supporting postoperative home follow-up for women after cesarean delivery. The resulting tool was designed for use in an implementation study of a novel CHW-led mHealth app. Methods: This study was conducted in the Kirehe district, Rwanda, from October 2022 to March 2023. We adapted 2 established tools—the mHealth App Usability Questionnaire and selected items from the Practitioner Opinion (Acceptability) Scale—and added new items that reflect core functions of the CHW-focused mHealth app. All items were translated into Kinyarwanda and simplified to align with CHWs’ educational levels. We conducted a three-stage validation that consisted of (1) content validity testing with 8 local and international experts using a recommended content validity index threshold of >0.78; (2) face validity testing with 10 CHWs using a recommended face validity index threshold of ≥0.60; and (3) reliability testing using responses from 30 CHWs, with a Cronbach α coefficient of ≥0.70 indicating acceptable internal consistency. Results: Of the 25 items assessed, 22 (88%) achieved a content validity index score of >0.78 for both clarity and relevance. The face validity index across all 22 items was 0.991, indicating strong comprehensibility and relevance to CHWs. Internal consistency was high: the Cronbach α was 0.86 for the mHealth App Usability Questionnaire items, 0.73 for the Practitioner Opinion (Acceptability) Scale items, and 0.87 for the newly developed questions. The final tool—named the Community Health Worker mHealth Usability and Acceptability Assessment Tool—included 22 items with strong content validity, face validity, and internal reliability. Conclusions: This study presents a rigorously adapted and validated tool for assessing mHealth usability and acceptability among CHWs in Rwanda. The Community Health Worker mHealth Usability and Acceptability Assessment Tool can guide future evaluations of mHealth interventions in similar contexts and serve as a model for localizing mHealth assessment tools in low- and middle-income country settings to ensure fit-for-purpose implementation.

Importance: Highlighting the global disparities in otolaryngology training and, ultimately, service delivery, emphasizing the need for equitable access to training resources and programs.Objective: To describe the relationship between the quality, content, and location of otolaryngology–head and neck surgery training and education and the resulting impact on the delivery of otolaryngology care globally.Design: An online cross‐sectional survey to otolaryngologists, gathering information on their training and education experiences, and factors influencing their choice of training location and practice.Setting: The online survey was available in multiple languages, distributed via national and international professional otolaryngology societies, snowballing and social media.Participants: The respondents were practicing otolaryngologists representing all seven World Health Organization regions.Exposures: World Bank income groups classification.Main Outcomes and Measures: Our expected outcome was that subspecialty training and access to educational resources were significantly readily available to respondents from high‐income countries, leading to more confidence in performing complex procedures post training.Results: A total of 91 participants were included in the analysis, with 47 (52%) practicing in high‐income countries and 44 (48%) in low‐ and middle‐income countries. Sixty‐one participants (67%) were male. Subspecialty training and access to educational resources were significantly less available in low‐ and middle‐income countries, leading to lower confidence among low‐ and middle‐income countries physicians in performing complex procedures. High‐income country respondents reported better access to diverse training resources and felt more prepared for a broader range of procedures.Conclusion and Relevance: Significant disparities exist in OHNS training resources and subspecialty training opportunities between high‐ and low‐middle‐income countries. There is a critical need to integrate complementary training and educational modalities into local systems. Addressing the shortage of educational resources and promoting open‐access initiatives in low‐middle‐income countries are essential steps toward enhancing surgical education and improving global otolaryngology healthcare outcomes.

Objective: This study aimed to assess the feasibility and acceptability of a new low‐cost otolaryngology simulation training curriculum for medical students in Rwanda. Given the limited access to hands‐on training and equipment in low‐middle‐income countries, building confidence in performing basic otolaryngology skills is vital for all medical students, especially where all graduates initially serve in primary care before specializing.Study Design: Preintervention and postintervention assessments of simulation training.Setting: Conducted at the University of Global Health Equity in Rwanda.Methods: The simulation program comprised 3 primary components: (1) a low‐cost, moderate‐fidelity model for cricothyrotomy and tracheostomy practice, (2) a low‐cost, low‐fidelity ear model for foreign body and cerumen removal, and a high‐fidelity manikin for practicing, (3) epistaxis management, and (4) nasal foreign body removal. Students underwent pretest and posttest assessments measuring their knowledge, experience, perceived skill, and confidence in performing these procedures. A survey collected feedback on the program.Results: A total of 29 medical students participated in the simulation program, integrated into a 1‐week otolaryngology “boot camp” preceding a 3‐week clerkship rotation. All models were created using basic, locally available materials, at a total cost of $1.02 for cricothyrotomy and $0.20 for foreign body models. Knowledge and perceived confidence increased for all 3 simulations. All students found the simulations useful, enjoyable, and anticipated using these skills in future training.Conclusion: The study's results demonstrated that the low‐cost otolaryngology simulation was well‐received and enhanced knowledge, interest, and confidence in performing basic otolaryngology skills across all simulations.

BACKGROUND Mobile health (mHealth) apps are increasingly leveraged to support community health workers (CHWs) in delivering high-quality care, particularly in low- and middle-income countries. However, despite the proliferation of mHealth tools, few have been implemented at scale, partly due to limited attention to usability and acceptability among end users. In sub-Saharan Africa, mHealth tools designed for CHWs often lack systematic evaluation using validated instruments tailored to local contexts. Without such assessments, it is difficult to ensure that these tools can be integrated effectively into CHW workflows and scaled sustainably. OBJECTIVE This study aimed to adapt and validate existing mHealth usability and acceptability assessment tools to be contextually appropriate for CHWs in Rwanda. Specifically, we sought to ensure contextual appropriateness for CHWs supporting postoperative home follow-up for women after cesarean delivery. The resulting tool was designed for use in an implementation study of a novel CHW-led mHealth app. METHODS This study was conducted in the Kirehe district, Rwanda, from October 2022 to March 2023. We adapted 2 established tools—the mHealth App Usability Questionnaire and selected items from the Practitioner Opinion (Acceptability) Scale—and added new items that reflect core functions of the CHW-focused mHealth app. All items were translated into Kinyarwanda and simplified to align with CHWs’ educational levels. We conducted a three-stage validation that consisted of (1) content validity testing with 8 local and international experts using a recommended content validity index threshold of >0.78; (2) face validity testing with 10 CHWs using a recommended face validity index threshold of ≥0.60; and (3) reliability testing using responses from 30 CHWs, with a Cronbach α coefficient of ≥0.70 indicating acceptable internal consistency. RESULTS Of the 25 items assessed, 22 (88%) achieved a content validity index score of >0.78 for both clarity and relevance. The face validity index across all 22 items was 0.991, indicating strong comprehensibility and relevance to CHWs. Internal consistency was high: the Cronbach α was 0.86 for the mHealth App Usability Questionnaire items, 0.73 for the Practitioner Opinion (Acceptability) Scale items, and 0.87 for the newly developed questions. The final tool—named the Community Health Worker mHealth Usability and Acceptability Assessment Tool—included 22 items with strong content validity, face validity, and internal reliability. CONCLUSIONS This study presents a rigorously adapted and validated tool for assessing mHealth usability and acceptability among CHWs in Rwanda. The Community Health Worker mHealth Usability and Acceptability Assessment Tool can guide future evaluations of mHealth interventions in similar contexts and serve as a model for localizing mHealth assessment tools in low- and middle-income country settings to ensure fit-for-purpose implementation.

Introduction: The objective of this paper is to discuss bidirectional innovation sharing between high-income countries (HICs) and low-income countries and middle-income countries (LMICs) in otolaryngology surgery. The authors aim to highlight several high-value, context-appropriate innovations in otolaryngology care that have been developed in a tertiary hospital in Rwanda and discuss their safety and efficacy compared to the standard of care. Methods: Five surgeons (three Rwandan surgeons, two United States surgeons with longitudinal experience in Rwanda) provided their recommendations for high-value innovations currently being employed in their experience at a tertiary hospital in Rwanda. Results: Otolaryngologists provided feedback on the utility, safety, and efficacy of ten ‘innovations’ that aim to optimize resource utilization and improve access to otolaryngology care. The authors emphasize the need for tailored, context-appropriate solutions in surgical care and the importance of research and evaluation to ensure the safety and efficacy of LMIC innovations. The authors also highlight the potential for HICs to learn from LMICs in terms of high-value and environmentally sustainable surgical practices. Further research is needed to guide national health systems in prioritizing their infrastructure, equipment, and training needs for scaling up otolaryngology services. Discussion: Our review highlights the importance of bidirectional learning in surgical innovation and the potential for high-value innovations to improve surgical care in LMICs.

Introduction/Background: Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda.Methods: We administered the Children's Surgical Assessment Tool, adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains.Results: None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure and information management for pediatric outpatients and referrals. In SSORT interviews (n = 47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score = 2.6 out of 5), psychological safety (median score = 3.0 out of 5), and resistance to change (mean score = 1.5 out of 5 with 5 = no resistance).Conclusions: This study highlights challenges in providing safe and high‐quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children's Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda. We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool. The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research. The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Article processing charges (APCs) for open access (OA) journals perpetuate inequities in scientific knowledge. High APCs systematically restrict low- and middle-income country (LMIC) researchers from contributing to research knowledge, preventing the dissemination of high-value, high-quality, and sustainable LMIC-driven solutions. Otolaryngology journals are no exception. The authors propose solutions to rectify the inequities in academic publishing because of APCs, including innovative solutions adopted by several major journals. Addressing these inequities requires medical society and journal editorial board leadership to ensure equitable APC policies.

Introduction: Most studies evaluating gender disparities in surgical specialties as a career choice are limited to high-income countries and have largely evaluated surgical subspecialties in aggregate. Objective: This study aimed to describe gender-based differences in otolaryngology specialty selection amongst medical students, trainees, and attendings/consultants across both low- and middle-income (LMICs) and high-income countries. Materials and methods: An online cross-sectional survey with 2 arms was administered. The first arm asked medical students about gender-related factors that impact interest in otolaryngology. The second arm asked otolaryngology residents and attendings about gender-related factors that impacted otolaryngology specialty selection and career satisfaction. Descriptive statistics were used to summarize patient demographics and survey responses. Responses were compared by gender using χ² and Fisher Exact tests. Subgroup analyses between gender and country income status were also conducted. Results: There were 67 medical student respondents (45% male, 54% female, 1.5% nonbinary) and 38 attending/consultant or resident respondents (47% male, 53% female, 0% nonbinary). Thirty-six (36%) of medical students were from LMICs, while 45% of attending/residents were from LMICs. Overall, the results demonstrated gender discrimination and gender-based barriers against female medical students considering otolaryngology and otolaryngologists worldwide that may not be recognized by their male colleagues. Conclusion: The results of these surveys highlight the need for continued education and anti-discrimination policy and advocacy in otolaryngology globally. This information can be leveraged to inform regionally specific research on gender disparities in the otolaryngology workforce and provide a foundation for initiatives to address gender disparities in otolaryngology programs.