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Background Community-based surveillance methods to monitor epidemiological progress in surgery have not yet been employed for surgical capacity building. The aim of this study was to create and assess the validity of a questionnaire that collected data for untreated surgically correctable diseases throughout Burera District, northern Rwanda, to accurately plan for surgical services. Methods A structured interview to assess for the presence or absence of ten index surgically treatable conditions (breast mass, cleft lip/palate, club foot, hernia or hydrocele [adult and paediatric]), hydrocephalus, hypospadias, injuries or wounds, neck mass, undescended testes, and vaginal fistula) was created. The interview was built based on previously validated questionnaires, forward and back translated into the local language and underwent focus group augmentation and pilot testing. In March and May, 2012, data collectors conducted the structured interviews with a household representative in 30 villages throughout Burera District, selected using a two-stage cluster sampling design. Rwandan physicians revisited the surveyed households to perform physical examinations on all household members, used as the gold standard to validate the structured interview. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all households. Findings 2990 individuals were surveyed, a 97% response rate. 2094 (70%) individuals were available for physical examination. The calculated overall sensitivity of the structured interview tool was 44·5% (95% CI 38·9–50·2) and the specificity was 97·7% (96·9–98·3%; appendix). The positive predictive value was 70% (95% CI 60·5–73·5), whereas the negative predictive value was 91·3% (90·0–92·5). The conditions with the highest sensitivity and specificity, respectively, were hydrocephalus (100% and 100%), clubfoot (100% and 99·8%), injuries or wounds (54·7% and 98·9%), and hypospadias (50% and 100%). Injuries or wounds and hernias or hydroceles were the conditions most frequently identified on examination that were not reported during the interview (appendix). Interpretation To the best of our knowledge, this study provides the first attempt to validate a community-based surgical surveillance tool. The finding of low sensitivity limits the use of the tool, which will require further revision, and calls into question previously published unvalidated community surgical survey data. To improve validation of community-based surveys, community education efforts on common surgically treatable conditions are needed in conjunction with increased access to surgical care. Accurate community-based surveys are crucial to integrated health system planning that includes surgical care as a core component. Funding The Harvard Sheldon Traveling Fellowship.

Background In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. Methods In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. Findings Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2–14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p Interpretation Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. Funding The Harvard Sheldon Traveling Fellowship.

Background A landmark study in 2009 demonstrated that a WHO surgical safety checklist decreased mortality and complications in surgical patients. Attempts to replicate this in the developing world have been mixed. We piloted the implementation of a surgical safety checklist with outcomes measurement in one district hospital in Rwanda, with the goal of creating a scalable model to use in all public hospitals in the country. Methods We sought to develop a conceptual and practical framework for ongoing outcomes measurement that can be applied to quality improvement projects in resource-poor settings. We accomplished this through interviews with global checklist implementation teams and Rwandan hospital staff, as well as observation. Findings We developed the following framework with specific examples from our experience. (1) Define the elements of data collection and who will perform each. In particular, the data audit function must be carefully outlined. (2) Understand the potential motivators for each participant in data collection and align incentives; these may be financial or non-financial. (3) Choose a data collection training method including initiation, maintenance, and troubleshooting. (4) Select a database software considering the following: availability of consistent or intermittent internet access, user interface complexity, flexibility of software for Mac and PC operating systems, need for mobile access, initial and ongoing costs, and technical support. Based on these criteria, we chose to pilot a new offline version of REDCap, which may have important implications for global health projects in settings without consistent internet access. (5) Be flexible. The framework provides a best first guess at the methods that will work for high-quality data collection, but a willingness to change course is critical. Interpretation Monitoring outcomes in quality improvement projects in resource-poor settings is difficult, but a framework makes it possible to effectively plan, initiate, and sustain data collection. Funding Lifebox Foundation, London, UK.