Long‐Term Impact of a Low‐Cost Paediatric Intussusception Air Enema Reduction Simulation‐Based Education Programme in a Low‐Middle Income Country

Abstract

Introduction Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Lowand 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 B 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.

Intussusception and COVID-19 in Children: A Systematic Review and Meta-Analysis

“…Whether differences in factors such as genetics, diet or environment could explain this increased risk remains unclear. However, the differences in the frates of ISN by ethnicity could possibly be explained by low socioeconomic status [ 72 ], difference in access to health care or lack of accessibility to medical treatment [ 73 ], health care-seeking behavior [ 74 ] or lack of awareness among parents when their child presents with symptoms of ISN leading them to seek medical attention [ 75 ]. ISN classically presents in an infant or toddler with sudden onset of intermittent, severe and progressive abdominal pain, accompanied by inconsolable crying often with vomiting, palpable sausage-shaped abdominal mass, red currant jelly stools, anorexia, dehydration, irritability, abdominal tenderness, lethargy and pallor [ 76 , 77 ].…”

A guide to outcome evaluation of simulation‐based education programmes in low and middle‐income countries

“…Historically, evaluation results were not necessarily published, but growing interest in translational research has resulted in a greater focus on evaluation studies, including in LMIC settings. 7,[16][17][18][19] Publishing evaluations disseminates information for use in similar contexts.…”

“…25 However, appropriate planning enables collection of qualitative and quantitative data to facilitate a comprehensive evaluation, including all levels, as was achieved for our intussusception project in Myanmar. 7,36 The Kirkpatrick model has been challenged for several reasons. 30,37,38 For example, Allen et al 30 highlighted that the focus on outcome evaluation means there is little consideration of how and why outcomes occur, and of the unintended impacts of programmes.…”

“…We have significant experience conducting SBE initiatives in a lower-middle-income country, the process of which has been described in detail elsewhere. 6,7,36,42 In brief, a multidisciplinary team designed and delivered 11 SBE courses in partnership with local paediatric surgeons and the University of Medicine 1 in Yangon, Myanmar, over a 4-year period. 6 These included scenariobased simulation, part-task trainers, and laparoscopic simulation.…”

“…4,5 This review aims to utilize our experience conducting SBE programmes in Myanmar (a lower-middle-income country) to provide a framework for designing evaluation processes in similar settings. 6,7 Core topics and relevant educational theory are described, including the Kirkpatrick model of evaluationan industry concept that has been successfully applied in multiple settings of medical education. [8][9][10] The benefits of evaluation and its important relationship with programme logic and planning are discussed.…”