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Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey
DOI 10.1371/journal.pone.0232320, Volume: 15, Issue: 4,
Abstract

IntroductionGlobal surgery is a growing field studying the determinants of safe and affordable surgical care and advocating to gain the global health community's attention. In Cameroon, little is known about the level of knowledge and attitudes of students. Our survey aimed to describe the knowledge and attitudes of Cameroonian medical students towards global surgery.Materials and methodsWe performed an anonymous online survey of final-year Cameroonian medical students. Mann-Whitney U test and Spearman correlation analysis were used for bivariate analysis, and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.Results204 respondents with a mean age of 24.7 years (±2.0) participated in this study. 58.3% were male, 41.6% had previously heard or read about global surgery, 36.3% had taken part in a global surgery study, and 10.8% had attended a global surgery event. Mercy Ships was well known (46.5%), and most students believed that surgical interventions were more costly than medical treatments (75.0%). The mean score of the global surgery evaluation was 47.4% (±29.6%), and being able to recognize more global surgery organizations was correlated with having assumed multiple roles during global surgery studies (p = 0.008) and identifying more global surgery indicators (p = 0.04). Workforce, infrastructure, and funding were highlighted as the top priorities for the development of global surgery in Cameroon.ConclusionMedical students are conscious of the importance of surgical care. They lack the opportunities to nurture their interest and should be taught global surgery concepts and skills.

Kanmounye, Mbonda, Djiofack, Daya, Pokam, Ghomsi, and Wright: Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey

Introduction

Two-thirds of the world’s population lacks access to safe, timely, and affordable surgical, obstetric, and anesthetic (SOA) care. [1] SOA public health interventions have traditionally been viewed as complicated and expensive, [2], and this has led to the relegation of SOA amenable diseases on national and international public health agendas. Global surgery is “an area for study, research, practice, and advocacy that seeks to improve health outcomes and to achieve health equity for all people requiring surgical care, with a special emphasis on underserved populations and populations in crisis.” [3] Eleven years ago, global surgery was referred to as the “neglected stepchild of global health.” [4] In 2015 however, the Lancet Commission on Global Surgery published a seminal report that emphasized the burden of SOA amenable diseases, defined six global indicators and corresponding targets to be attained by 2030 and advocated for health systems strengthening through national surgical, obstetrics and anesthesia plans (NSOAPs). [5] During the same year, the World Health Assembly passed resolution WHA 68.15, which emphasized the importance of SOA care in achieving universal health coverage. [6] As we strive to achieve universal health coverage, we must remember that “no country can achieve universal health coverage unless its people have access to safe, timely and affordable [SOA] services.” [7]

Global surgery transcends the operating room and the perioperative period spatially and temporally and addresses the causes of the three delays of access to SOA care: delay in seeking, reaching, and accessing safe, timely, and affordable SOA care. NSOAPs “provide a vision, along with costed- and time-bound targets, of how actors within the SOA system will work together to systematically improve the SOA health system.” [8] Practically, this translates to eight steps: securing support from relevant government institutions; evaluation of the current SOA system; involvement of SOA system actors and priority setting; design and approval of a plan; monitoring and evaluation; budgeting; improved governance; and implementation. [9] Locally driven research, advocacy at high-level meetings and the ministerial level, and education aimed at health systems strengthening in underserved populations are indispensable to the development of effective NSOAPs.

Cameroon is a Central African country with a population of 25 million. [10] Most Cameroonians live within 2-hours of a public, a private for-profit, a private not-for-profit, or a faith-based healthcare facility offering essential SOA care. [11] This geographical proximity is, in reality, limited by the lack of financial risk protection as 63% of total SOA care expenditures are paid out-of-pocket by patients and their families. [12] Surgical safety is a concern in Cameroon, given the 7-day postoperative complication rate is at 13.1%, and the postoperative mortality rate is at 2%. [13] While these numbers are similar to those of other African countries, they remain high when compared to those of high-income countries. During the last human resources for health census in 2011, Cameroon had 153 surgeons, 140 obstetricians, and 22 anesthesiologists [14]. Public, faith-based, and private secular organizations offer surgical care in Cameroon. Faith-based organizations offer surgical care for free or at reduced costs, mostly in rural areas and to low-income families in urban areas. Since medical students form the national potential in workforce capacity development, their attitudes towards global surgery are of paramount importance. Despite the growing interest in global surgery in the country, no data is currently available on the knowledge and attitudes of medical students towards global surgery.

Materials and methods

The institutional review board of Université des Montagnes authorized this study. We carried out a literature review to inform our questionnaire on landmark global surgery findings [1,2,5,13,15,16], and we submitted the questions to three experts who established the face validity of the survey. The online survey was anonymous, administered in official languages (French and English), and hosted on Google Forms (Alphabet Inc., California, USA). We then piloted our survey among 20 Cameroonian medical students. Responses to the pilot survey were excluded, and all issues raised during the pilot were addressed. We distributed the survey link to class representatives of our target population (final year medical students in Cameroon). The class representatives then went on to distribute the survey links in the official class WhatsApp groups (Facebook Inc., California, USA). WhatsApp is the primary means of formal communication among medical students, so all students join the official class group. We collected the total number of students in each group to calculate the participation rate, link dissemination was confirmed by screenshots, and reminder messages were sent every week in the class groups to ensure a reasonable participation rate.

We collected sociodemographic information, assessed knowledge, and perceptions of our respondents about global surgery. Survey questions were a mix of open, close, multiple-choice, and Likert scale questions. Data on negatively phrased questions were reversed coded to ensure consistency with positively phrased questions that were similar. The data collected were coded and tidied on Excel 2016 (Microsoft Corp., Washington, USA). We analyzed bivariate data using the Mann-Whitney U test and Spearman correlation on SPSS version 24 (IBM, New York, USA). The threshold of significance was set at 0.05. Data collection complied with the terms and conditions of Google Forms.

Results

We received 204 responses (participation rate: 84.3%, n = 242) from final year medical students enrolled at all of the six Cameroonian medical schools. The students resided in seven of the ten Cameroonian regions (Fig 1), they had a mean age of 24.7 years (±2.0), and 119 (58.3%) were male. 91 students (41.6%) had previously heard or read about global surgery, 74 (36.3%) had previously participated in a global surgery study, and 22 (10.8%) had attended a global surgery event. Only 15 students (7.4%) had both previously participated in a global surgery study and attended a global surgery event. Table 1 summarizes the students’ global surgery experiences by sex.

Medical school locations and permanent residencies of medical students.
Fig 1
Regions of permanent residence are colored in blue. Buildings represent medical schools, and icon heads donning graduate caps represent medical students. The number of medical students and medical schools is placed below the corresponding icons.Medical school locations and permanent residencies of medical students.
Table 1
Global surgery experiences of cameroonian final year medical students.
CharacteristicFemale (%)Male (%)OR (95% CI) a
Heard or read about global surgery (via)38 (18.63)53 (25.98)0.99 (0.57–1.73)
    Acquaintance920
    Hospital109
    School1818
    Social media1342
    Television52
    Other43
Number of media through which students learned about global surgery
    131 (15.19)33 (16.17)
    24 (1.96)5 (2.45)
    32 (0.98)8 (3.92)
    42 (0.98)4 (1.96)
    51 (0.49)2 (0.98)
Attendance at a global surgery event7 (3.43)15 (7.35)1.61 (0.63–4.13)
    In-person in Cameroon59
    In-person abroad01
    Online25
Participation in global surgery research27 (13.24)47 (23.04)1.40 (0.78–2.52)
    Collaborator511
    Data collector813
    Investigator57
    Respondent1217
Number of roles assumed by the students
    125 (12.25)36 (17.65)
    206 (2.94)
    31 (0.49)2 (0.98)
a Odds ratio for sex (Female/Male)

46 students (22.5%) defined “global surgery” correctly. We considered a definition to be correct if it used the following set of terms or their synonyms: “surgery,” “everyone,” “everywhere,” and “access.” Global surgery was most often mistaken to mean “general surgery” or was thought to be “a multidisciplinary surgical team.” 32 respondents (15.7%) could not identify or cite a global surgery organization, whereas 106 (52.0%) could only identify one organization. The most commonly cited organizations were Mercy Ships (46.5%), InciSioN (21.3%), and the Lancet Commission on Global Surgery (8.9%). 162 students (79.4%) recognized a single global surgery indicator. Access to timely essential surgery was the most widely known global surgery indicator (39.3%). Other popular indicators included perioperative mortality rate (25.5%), specialist surgical workforce density (16.1%), and risk of impoverishing expenditure (7.1%). The risk of catastrophic expenditure (6.4%) and the surgical volume (5.6%) were the least popular of all global surgery indicators. Four students (2.0%) had read or heard about national surgical, obstetric, and anesthesia plans, while only 3 students (1.5%) knew about the disease control priorities 3 essential surgeries.

Students were asked questions that were based on the key findings of landmark global surgery papers. The mean score for this quiz was 47.4% (±29.6%), with 108 students (52.9%) performing below average. Unsurprisingly, having heard or read about global surgery (p = 0.047) was significantly associated with a better performance at the quiz, unlike participation in a global surgery study (p = 0.68) and attendance at a global surgery event (p = 0.34). Recognition of global surgery organizations was correlated with having assumed more roles (collaborator, data collector, or investigator) in global surgery studies (p = 0.008) and recognition of global surgery indicators (p = 0.04).

Most students (62.7%) believed surgically amenable diseases were a significant public health problem in Cameroon; however, 153 (75.0%) felt that surgical interventions cost more than medical treatments. 157 (77.0%) supported task-shifting as a solution to lessen the burden of surgically amenable diseases. The students identified workforce, investment in tertiary level facilities, and funding as priorities for the attainment of universal access to surgical, obstetric, and anesthetic care in Cameroon (Fig 2).

Global surgery priorities in Cameroon according to final year medical students.
Fig 2
Global surgery priorities in Cameroon according to final year medical students.

Discussion

The majority of final year Cameroonian medical students have never heard or read about global surgery. They learned about global surgery primarily on social media, and few have had the opportunity to participate in global surgery research or to attend global surgery events. The fact that social media ranked ahead of medical school and teaching hospital lectures reinforces the notion that social media is a tool for research, education, and advocacy dissemination in global surgery. [17] We recommend a change in the undergraduate curriculum to include at least one lecture on global surgery. Mercy Ships was the most widely known global surgery institution among medical students. The popularity of Mercy Ships can be attributed to its recent year-long surgical mission to Cameroon. [18]

Generally, respondents were not comfortable dealing with global surgery concepts and literature. Unsurprisingly, students who had more global surgery research experience performed better at the quiz. The subpar performance of the respondents could be explained by the lack of global surgery research and education opportunities. Exposure to global surgery has been shown to raise the interest of future global surgeons. [19] Despite the popularity of global surgery, opportunities are scarce. Students at American and Canadian schools report having limited global surgery opportunities. [20,21] Among the few global surgery opportunities in the global surgery course developed by Lund University, Harvard Medical School, and the University of Zimbabwe. [22] This course is run for five weeks, and it combines theory and practice in a low resource setting. Another opportunity is the research associate fellowships offered by the Program in Global Surgery and Social Change, Harvard Medical School. This position goes to 5–8 senior medical students from all over the world each year. [23] Global surgery conferences equally represent an opportunity for students to learn. Students gain valuable skills at global surgery academic events. [21,24] Some global surgery conferences include the COSECSA annual meeting, the Consortium of Universities in Global Health, Bethune round table, InciSioN Global Surgery Symposium, and Global Surgery Student Alliance symposium.

Students are already contributing to global surgery research and education. The British student research collaborative, STARSurg, is currently running global pediatric surgery studies in Tanzania. [25] In Rwanda, students assisted their government during the NSOAP design, collecting data all around the country. Pleased with the contribution of medical students, the government went on to integrate strategies aimed at increasing global surgery involvement among medical students in the NSOAP. [26]

Surgically amenable diseases affect people of all ages, genders, and nationalities. However, most of the 5 billion people who have limited access to safe, timely, and affordable SOA care are either citizens of low- and middle-income countries or residents of underserved regions in high-income countries. [1] Medical students from these regions can contribute to the attainment of universal access to surgical care if they are given the skills and opportunities. Social media play a critical role in the dissemination of global surgery research, advocacy, and education among medical students.

We acknowledge the following limitations in our study. First, we contacted students via the class WhatsApp groups. This mode of dissemination might have led to undercoverage bias, or nonresponse bias of our study population given as individuals from lower-income groups might not be able to afford data plans. We reduced nonresponse bias by sending weekly reminder messages, and we obtained students' phone numbers and the total number of enrolled students from class delegates. Our participation rate suggests that the risks of these biases were minimal in our survey. Other limitations include variations in understanding the questions, the limitations of areas of questioning encompassed by the survey, and the unproven generalizability of our findings to other LMICs.

Conclusion

The majority of final year medical students do not understand or know what global surgery is. Few students have had the opportunity to participate in global surgery research or events, but students are aware of the health and social impacts of surgically amenable diseases. When they are given access to resources, students contribute to research, education, and advocacy in the field and are more likely to pursue a global surgery career. The emphasis, therefore, should be laid on increasing the involvement of medical students in global surgical education and activities.

Acknowledgements

We wish to thank Dominique Vervoort for his help in proofreading this manuscript. We wish to acknowledge Anudari Zorigtbaatar, Nabeel Muhammad, and Desmond Jumbam for their help with the face validity of the survey.

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9 Jan 2020

PONE-D-19-34339

Knowledge and Attitudes of Medical Students and Healthcare Workers Towards Global Surgery in Cameroon

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Additional Editor Comments:

There are significant issues identified by the reviewers. I want to highlight two

1. This study would not be appropriate for publication in PLOS ONE unless the application of the findings would be wider than Cameroon.

2. If the authors would want to have the study published in this journal, I would suggest redoing the questionnaire, and showing clearly how questions were asked. They could then administer it to a homogenous group such as all final year medical students in the country, and find a way to achieve a high response rate (preferably 80% or above).

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Reviewer #1: The paper reads well but is primarily a discussion on global surgery. There is clearly a need to develop surgical services in Cameroon, but does the workforce need to advocate global surgery or to focus on developing surgical services in Cameroon itself? The latter is likely more important. There should be details included of the plans for Cameroon to develop their surgical services and whether the government is guided by global health targets.

The contribution of Mercy Ships is well made through the lead in training and providing a vital service for the local community.

I believe this paper is worthy of publication but more as a discussion of the need for countries (like Cameroon) to work towards achieving Global Surgery targets. The questionnaire is more of a side discussion.

Statistics are included in the paper but do not add to the analysis and should be removed.

Reviewer #2: I am interested that the lead researcher appears to be based in DR Congo and ethics was approved there, although the study was conducted in Cameroon. This seems to conflict with line 117 where the manuscript states that local ethical approval was obtained.

The introduction is nicely constructed and builds to the purpose of this study.

It would be very helpful to have some workforce data for Cameroon. Eg what percentage of doctors registered in Cameroon work in anaesthetic, obstetric or surgical disciplines?

Line 92 I am unsure what the authors mean when they say that global surgery in Cameroon is ‘led’ by InciSioN? Do they mean that InciSioN is one of the leading pressure groups promoting global surgery?

Line 101-102: I feel that the authors could emphasize the wider potentials for the study. This study would not be appropriate for publication in PLOS ONE unless the application of the findings would be wider than Cameroon.

In Methods the authors first describe how they designed their survey line107. This section is brief and the reader only really knows which literature was read.

The questionnaire itself needs to be seen so that readers can see how questions were expressed, and could repeat the study in their own country or at a different time.

The authors then describe how they found their participants for the study. Their description is not very clear – either in terms of how they selected or accessed their target audience. They say that they used a convenience non-probability sampling method but do not reference this or explain how it worked , line 112.

They do not state how many people received the questionnaire, and hence the response rate is not evident.

It is very hard to know how representative their sample is likely to be.

In line 112,113 I am unsure why they chose medical Students and nurses and doctors including surgeons. It seemed to be anyone who was willing to complete the survey. The study would have more clarity if it was a single target audience. It is hard to imagine the respondents did not self-select as those interested in the topic. The groups sampled cross professions and training/trained demographics. For the medical students we are not told in which year of study they are currently. Clearly a first year medical student would have less chance of understanding global surgery than a final year student. We are not told if there is teaching on this subject in the medical student curriculum, and if so in which year of study it is taught?

The forms were anonymous but the authors say that they omitted members of the InciSioN group – how did they do this?

Results

Line 121 there were only 45 respondents. We are not informed how many medical students are present in Cameroon, or indeed health care workers.

Line 129: do the authors mean most popular (well thought of) or popular (well known).

In the table:

Health professionals presumably means 18 doctors and one nurse?

The question ‘do you know about ‘global surgery’ appears confusing, and might be better expressed ‘have you previously heard of the term ‘global surgery’?’

For all the summarised section results it is unclear whether or not these are based on open or closed questions. For example were the organisations named and the respondents stated whether or not they had heard of them, or were they free text responses conceived by respondents?

Line 144 some results are given in the text but not in the table whilst others are in the table and repeated in the text. This needs to be consistent.

Having not seen the questionnaire I am unsure whether any questions explored the place of trauma and injury in surgically treatable disease. This is particularly relevant to the perception of surgically treatable disease as a public health issue.

Discussion

The discussion is quite long but rather mono-focussed.

There is no comment on similar literature.

There is some discussion regarding why respondents responded as they did.

Much of the focus seems to bear on proposed solutions to spread the word regarding global surgery, and a bit of publicity for InciSioN Cameroon. It would be helpful if the authors explored the issue of current knowledge and understanding of global surgery without such particular emphasis on InciSioN.

Conclusion

Line 225 the authors state their laudable organisational aims. However it would be helpful if the manuscript could be expressed a little more objectively and scientifically.

Figure

The authors show the type and distribution of respondents. It would be helpful to know where the medical schools are distributed and how many medical students are present in each.

Reviewer opinion:

The authors have an original and interesting research concept. The authors are to be thanked for raising this debate and taking time to undertake this survey and prepare the manuscript.

I agree with them that this subject is of importance in the Universal health Coverage debate. They also clearly have great passion for their subject material. They have presented some interesting findings, and make some interesting proposals.

The big challenge here is the methodology. Details of this are noted in my comments. The likelihood of self-selection of respondents and the heterogeneity of the sample render the results impossible to analyse or to use for meaningful conclusions. The sample size is relatively small. Even with improved explanation of the methodology used, I think there would be too many concerns on methodology to enable the results to be published.

If the authors would want to have the study published in this journal, I would suggest redoing the questionnaire, and showing clearly how questions were asked. They could then administer it to a homogenous group such as all final year medical students in the country, and find a way to achieve a high response rate (preferably 80% or above).

Is it new? Yes

Is it of interest and value? Yes

Does the science stand up? No

Recommendation: not suitable for publication without complete revision of study (not just of manuscript).

**********

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Reviewer #1: No

Reviewer #2: No

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21 Feb 2020

Dear Editor and Dear reviewers,

We wish to thank you for taking the time to review our manuscript. The suggestions you made and the questions you raised were very helpful and accurate. We have addressed your comments and we feel this has substantially improved the quality of our manuscript. We look forward to reading your comments.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper reads well but is primarily a discussion on global surgery. There is clearly a need to develop surgical services in Cameroon, but does the workforce need to advocate global surgery or to focus on developing surgical services in Cameroon itself? The latter is likely more important. There should be details included of the plans for Cameroon to develop their surgical services and whether the government is guided by global health targets.

Re: Dear reviewer, thank you for this valuable comment. The public health system in Cameroon is very centralized: key decisions are made at the Ministry of Health (MoH) level based on information gathered at the peripheral level (district hospitals). The information gathered peripherally is relayed to the central MoH by multiple mid-level administrative bodies. As a result, bureaucracy delays responses from the MoH and leads to a fragmentation of the public health system.

Another problem is the earmarking of funds for diseases such as HIV/AIDS, Malaria and Tuberculosis. This has created a disparity between these high-profile diseases and other diseases. For example, most performance-based financing indicators are focused on infectious diseases, non-surgical maternal health and non-surgical child health. Consequently, the provision of care is skewed towards the incentivized diseases to the detriment of the other diseases. This gives the impression that the burden of the non-incentivized diseases is small or negligible. We believe the workforce can advocate for surgically amenable diseases if they advocate for the non-incentivized diseases. They have a role to play in surgical services delivery in Cameroon but at the moment their capacity is limited by non-recognition of the burden of surgically amenable diseases.

The contribution of Mercy Ships is well made through the lead in training and providing a vital service for the local community.

I believe this paper is worthy of publication but more as a discussion of the need for countries (like Cameroon) to work towards achieving Global Surgery targets. The questionnaire is more of a side discussion.

Statistics are included in the paper but do not add to the analysis and should be removed.

Re: Dear reviewer, we share your opinion on the quality of the survey. Following advice from the academic editor, we re-administered the survey to a more homogenous population (final year medical students). We ran summary descriptive analysis and non-parametric bivariate analysis. As a result, we have rewritten the results and discussion sections to reflect this change.

Reviewer #2: I am interested that the lead researcher appears to be based in DR Congo and ethics was approved there, although the study was conducted in Cameroon. This seems to conflict with line 117 where the manuscript states that local ethical approval was obtained.

Re: Dear reviewer, thanks for taking the time to review our article. We found your comments accurate and beneficial. We had obtained IRBs at the academic institutions of the authors in Cameroon and DR Congo. We have attached the IRB obtained in Cameroon to this submission.

The introduction is nicely constructed and builds to the purpose of this study.

It would be very helpful to have some workforce data for Cameroon. Eg what percentage of doctors registered in Cameroon work in anaesthetic, obstetric or surgical disciplines? http://cm-minsante-drh.com/site/images/stories/Rapport_general_du_recensement01_12_2011_misenforme_FINAL05122001.pdf

Re: Thank you for your advice and kind words. We agree with you that having workforce data will make for a better read. We have included data on the surgical, obstetric and anesthesia workforce in the manuscript (lines 101-102).

Line 92 I am unsure what the authors mean when they say that global surgery in Cameroon is ‘led’ by InciSioN? Do they mean that InciSioN is one of the leading pressure groups promoting global surgery?

Re: Dear reviewer, we agree with you. We meant that InciSioN is one of the leading pressure groups promoting global surgery. We opted to exclude this statement as well as most mentions of InciSioN in the manuscript. As you rightfully noted our paper was monofocused.

Line 101-102: I feel that the authors could emphasize the wider potentials for the study. This study would not be appropriate for publication in PLOS ONE unless the application of the findings would be wider than Cameroon.

Re: Dear reviewer, we have rewritten our discussion to emphasize the wider potential of the study in the United States and low- and middle-income countries.

In Methods the authors first describe how they designed their survey line107. This section is brief and the reader only really knows which literature was read.

Re: Dear reviewer, thanks for your remark. Per your recommendation we have rewritten the methods and given additional details.

The questionnaire itself needs to be seen so that readers can see how questions were expressed, and could repeat the study in their own country or at a different time.

Re: We apologize for this mistake. We have added the questionnaire to the resubmission.

The authors then describe how they found their participants for the study. Their description is not very clear – either in terms of how they selected or accessed their target audience. They say that they used a convenience non-probability sampling method but do not reference this or explain how it worked, line 112.

They do not state how many people received the questionnaire, and hence the response rate is not evident.

It is very hard to know how representative their sample is likely to be.

Re: Dear reviewer, we have addressed recruitment, response rate and representativeness in our methods (lines 115-121).

In line 112,113 I am unsure why they chose medical Students and nurses and doctors including surgeons. It seemed to be anyone who was willing to complete the survey. The study would have more clarity if it was a single target audience. It is hard to imagine the respondents did not self-select as those interested in the topic. The groups sampled cross professions and training/trained demographics. For the medical students we are not told in which year of study they are currently. Clearly a first year medical student would have less chance of understanding global surgery than a final year student. We are not told if there is teaching on this subject in the medical student curriculum, and if so in which year of study it is taught?

The forms were anonymous but the authors say that they omitted members of the InciSioN group – how did they do this?

Re: Following your remarks and those of the academic editor we re-administered the survey to a homogenous population of seventh-year medical students. Our previous response rate had been affected by the conflicts in the North West and South West regions of Cameroon – where two of the six medical schools are located. We have been able to reach a much wider audience, ensuring generalizability.

Results

Line 121 there were only 45 respondents. We are not informed how many medical students are present in Cameroon, or indeed health care workers.

Re: Dear reviewer, we have re-administered the survey and rewritten both the methods and results to address this issue.

Line 129: do the authors mean most popular (well thought of) or popular (well known).

In the table:

Health professionals presumably means 18 doctors and one nurse?

Re: Dear reviewer, we have re-administered the survey to final year medical students and rewritten both the results and discussion.

The question ‘do you know about ‘global surgery’ appears confusing, and might be better expressed ‘have you previously heard of the term ‘global surgery’?’

Re: We agree with you esteemed Dr. The question is phrased as you suggested in our survey form which has been submitted along with this response.

For all the summarised section results it is unclear whether or not these are based on open or closed questions. For example were the organisations named and the respondents stated whether or not they had heard of them, or were they free text responses conceived by respondents?

Re: We have submitted the survey form along with this letter. The organizations were listed and the respondents could list an organization if it was not on the list.

Line 144 some results are given in the text but not in the table whilst others are in the table and repeated in the text. This needs to be consistent.

Re: Thanks Dr. We have attended to this in our new Table 1 (line 145).

Having not seen the questionnaire I am unsure whether any questions explored the place of trauma and injury in surgically treatable disease. This is particularly relevant to the perception of surgically treatable disease as a public health issue.

Re: We agree with you. We opted to limit our questions to the basic concepts of global surgery because there are other key concepts such as emergency obstetric care and emergency laparotomies that are just as deserving but would have lengthened the survey.

Discussion

The discussion is quite long but rather mono-focussed.

There is no comment on similar literature.

Re: Thanks for your insightful comment. We have rewritten the discussion.

There is some discussion regarding why respondents responded as they did.

Much of the focus seems to bear on proposed solutions to spread the word regarding global surgery, and a bit of publicity for InciSioN Cameroon. It would be helpful if the authors explored the issue of current knowledge and understanding of global surgery without such particular emphasis on InciSioN.

Re: We have rewritten the discussion to be less monofocused.

Conclusion

Line 225 the authors state their laudable organisational aims. However, it would be helpful if the manuscript could be expressed a little more objectively and scientifically.

Re: You are right dear reviewer. We have rewritten the conclusion to be less passionate and more scientific.

Figure

The authors show the type and distribution of respondents. It would be helpful to know where the medical schools are distributed and how many medical students are present in each.

Re: Following your advice, we have redesigned the figure to show the location of the medical schools.

Reviewer opinion:

The authors have an original and interesting research concept. The authors are to be thanked for raising this debate and taking time to undertake this survey and prepare the manuscript.

I agree with them that this subject is of importance in the Universal health Coverage debate. They also clearly have great passion for their subject material. They have presented some interesting findings, and make some interesting proposals.

The big challenge here is the methodology. Details of this are noted in my comments. The likelihood of self-selection of respondents and the heterogeneity of the sample render the results impossible to analyse or to use for meaningful conclusions. The sample size is relatively small. Even with improved explanation of the methodology used, I think there would be too many concerns on methodology to enable the results to be published.

If the authors would want to have the study published in this journal, I would suggest redoing the questionnaire, and showing clearly how questions were asked. They could then administer it to a homogenous group such as all final year medical students in the country, and find a way to achieve a high response rate (preferably 80% or above).

Submitted filename: Response to Reviewers.docx

23 Mar 2020

PONE-D-19-34339R1

Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: a web-based survey

PLOS ONE

Dear Dr. Kanmounye,

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PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors should be congratulated for a thorough reworking of the paper and their commitment demonstrated by carrying a wider survey. I believe this paper is a useful contribution to the literature and I hope the aims of there authors to raise the profile of surgical care in Cameroon will be met.

2 minor comments:

Line 39: only medical students completed the questionnaire

Line 148: typo- remove 'were'

Reviewer #2: Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: a web based survey

Reviewer comments:

Answering questions raised: the authors have been at pains to answer the questions and respond to the issues raised in the review of the first manuscript. They have gone to the lengths of completely re-administering the questionnaire and rewriting the whole manuscript. Effectively they have gone to the length of starting from scratch with the same concept but delivered with a greatly enhanced methodology.

Abstract: in results I would say 58% of respondents were male – rather than ‘most’.

The authors say that the mean knowledge level was 47%. The terminology ‘knowledge level’ is difficult for the reader to understand or quantify. The terminology assuming ‘numbers of roles’ is not easily understood by the reader.

Introduction:

This is nicely constructed with quotations which highlight the importance of the topic. It builds towards the purpose of the study. There is a slightly abrupt transition from the global surgical need to the knowledge and opinions of medical students. Perhaps a bridging sentence such as ‘since Medical Students form the national potential in workforce capacity development, their attitudes towards global surgery are of paramount importance.’

Methodology:

This description is now succinct and much easier to understand than previously. The target group is homogenious and quantifiable.

A pilot study was used to hone the quality of the questionnaire.

I would still really like to see the survey rather than just a link to it. This would be one of my main recommendations.

Results:

Since the aim is to look at Medical student knowledge and attitude, I am unsure as to why the results are divided by sex? The aim was not to look as sex differences in attitude and knowledge. No gross differences emerge, so why not simply present the results for all respondents and say that no significant differences were observed based on the sex of the student?

I am not sure that figure 1 adds a huge amount. The main question seems to be - of the six medical schools in the country, what was the variation in participation rate? This may affect the generalizability of the findings.

The results summarized in the text lines 148-174 are useful and interesting.

Line 167 assuming numbers of roles is not understood to this reviewer and therefore probably not to most readers. Can this be defined?

Figure 2 is quite useful in allowing the reader to compare the strength of opinion relating to the responses with Likert grades.

Discussion:

The discussion is much improved from last time with some comparison to other studies and broader assessment of the impact of educating medical students regarding global surgery.

I am interested that the authors do not recommend a change in the undergraduate curriculum to include at least on lecture on global surgery, and perhaps another on universal health access? What they seem to have discovered is that social media and external events are moderately effective in filling a gap in the curriculum. It seems reasonable that they should advocate for that gap to be filled.

When discussing the limitations the authors focus on survey uptake and whether the sample is representative. In fact this has become a strength of the study with more than 80% response rate.

Other limitations would include:

Variations in understanding the questions; limitations of areas of questioning encompassed by the survey; unproven generalizability of these results to other lmics.

Conclusion:

The conclusion is a little wordy. The last sentence is a good one but perhaps should say ‘in global surgical education and activities’.

Overall reviewer opinion:

This is a vastly improved and totally reworked manuscript. It is an important area of research. It is now a coherent study. I would recommend it as being suitable for publication subject to a few minor edits.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Richard O.E. Gardner

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.


24 Mar 2020

Response to reviewers below the "R:"

Reviewer #1: The authors should be congratulated for a thorough reworking of the paper and their commitment demonstrated by carrying a wider survey. I believe this paper is a useful contribution to the literature and I hope the aims of there authors to raise the profile of surgical care in Cameroon will be met.

R:

Dr Gardner, this was possible thanks to you. Your comments greatly improved our manuscript.

2 minor comments:

Line 39: only medical students completed the questionnaire

R: We have corrected the sentence. (Line 39-40)

Line 148: typo- remove 'were'

R: Thanks. The typo has been corrected. (Line 151)

Reviewer #2: Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: a web based survey

Reviewer comments:

Answering questions raised: the authors have been at pains to answer the questions and respond to the issues raised in the review of the first manuscript. They have gone to the lengths of completely re-administering the questionnaire and rewriting the whole manuscript. Effectively they have gone to the length of starting from scratch with the same concept but delivered with a greatly enhanced methodology.

R:

Thank you for your comments and kind words. You made this process enjoyable and rewarding. We learnt a lot.

Abstract: in results I would say 58% of respondents were male – rather than ‘most’.

R:

Thank you for pointing this out. We have made the changes suggested. (Lines 50-51)

The authors say that the mean knowledge level was 47%. The terminology ‘knowledge level’ is difficult for the reader to understand or quantify. The terminology assuming ‘numbers of roles’ is not easily understood by the reader.

R:

We have reworded the text and we hope it is clearer for the audience. (Line 53-57)

Introduction:

This is nicely constructed with quotations which highlight the importance of the topic. It builds towards the purpose of the study. There is a slightly abrupt transition from the global surgical need to the knowledge and opinions of medical students. Perhaps a bridging sentence such as ‘since Medical Students form the national potential in workforce capacity development, their attitudes towards global surgery are of paramount importance.’

R:

Thank you. We have made changes to the introduction. (Lines 105-107)

Methodology:

This description is now succinct and much easier to understand than previously. The target group is homogenious and quantifiable.

A pilot study was used to hone the quality of the questionnaire.

I would still really like to see the survey rather than just a link to it. This would be one of my main recommendations.

R:

We are sorry for the inconvenience caused. Following your initial comments, we had submitted the questionnaire as a supplemental file. However, it seems you did not get the file. We have resubmitted the questionnaire.

Results:

Since the aim is to look at Medical student knowledge and attitude, I am unsure as to why the results are divided by sex? The aim was not to look as sex differences in attitude and knowledge. No gross differences emerge, so why not simply present the results for all respondents and say that no significant differences were observed based on the sex of the student?

R:

Thank you for your comments. Although the sex disparities were not statistically significant, the differences between the two genders were important. It is possible that we were not powered to detect the differences in gender. Surgery and global surgery are fields dominated by men and we felt it was critical to report on the gender differences (Odds ratio of female/male 1.61 and 1.40). We presented these results to highlight this too. With your permission we wish to keep these results.

I am not sure that figure 1 adds a huge amount. The main question seems to be - of the six medical schools in the country, what was the variation in participation rate? This may affect the generalizability of the findings.

R:

Dear reviewer, we added figure 1 at the request of reviewer 1 who felt it was important to show the distribution of participants.

The results summarized in the text lines 148-174 are useful and interesting.

R:

Thank you

Line 167 assuming numbers of roles is not understood to this reviewer and therefore probably not to most readers. Can this be defined?

R:

Dear reviewer, thank you for your comments. We have reworded the sentence. (Lines 170-172)

Figure 2 is quite useful in allowing the reader to compare the strength of opinion relating to the responses with Likert grades.

R:

Thank you.

Discussion:

The discussion is much improved from last time with some comparison to other studies and broader assessment of the impact of educating medical students regarding global surgery.

R:

We are honored by your comments and grateful for your help.

I am interested that the authors do not recommend a change in the undergraduate curriculum to include at least on lecture on global surgery, and perhaps another on universal health access? What they seem to have discovered is that social media and external events are moderately effective in filling a gap in the curriculum. It seems reasonable that they should advocate for that gap to be filled.

R:

Thank you for pointing this out. We have added your suggestion to the discussion. (Line 187-188)

When discussing the limitations the authors focus on survey uptake and whether the sample is representative. In fact this has become a strength of the study with more than 80% response rate.

Other limitations would include:

Variations in understanding the questions; limitations of areas of questioning encompassed by the survey; unproven generalizability of these results to other lmics.

R:

We have added these to our limitations. (Lines 227-229)

Conclusion:

The conclusion is a little wordy. The last sentence is a good one but perhaps should say ‘in global surgical education and activities’.

R:

We have rewritten the conclusion per your recommendation. (Conclusion)

Overall reviewer opinion:

This is a vastly improved and totally reworked manuscript. It is an important area of research. It is now a coherent study. I would recommend it as being suitable for publication subject to a few minor edits.

R:

This would not have been possible without your help. Thank you for your patience and assistance all throughout this process.

Submitted filename: Response to Reviewers.docx

14 Apr 2020

Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: a web-based survey

PONE-D-19-34339R2

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James G. Wright

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

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Comments to the Author

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Reviewer #2: All comments have been addressed

**********

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

**********

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Reviewer #2: (No Response)

**********

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Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

**********

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

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Reviewer #2: No


21 Apr 2020

PONE-D-19-34339R2

Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: a web-based survey

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PLOS ONE Editorial Office Staff

on behalf of

Professor James G. Wright

Academic Editor

PLOS ONE

https://www.researchpad.co/tools/openurl?pubtype=article&doi=10.1371/journal.pone.0232320&title=Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey&author=Ulrick S. Kanmounye,Aimé N. Mbonda,Dylan Djiofack,Leonid Daya,Ornella F. Pokam,Nathalie C. Ghomsi,James G. Wright,James G. Wright,James G. Wright,James G. Wright,James G. Wright,&keyword=&subject=Research Article,Medicine and Health Sciences,Surgical and Invasive Medical Procedures,Medicine and Health Sciences,Surgical and Invasive Medical Procedures,Obstetric Procedures,Medicine and Health Sciences,Public and Occupational Health,Global Health,Medicine and Health Sciences,Health Care,Health Care Policy,Health Systems Strengthening,People and Places,Geographical Locations,Africa,Cameroon,Social Sciences,Sociology,Education,Medical Education,Medicine and Health Sciences,Medical Humanities,Medical Education,Medicine and Health Sciences,Surgical and Invasive Medical Procedures,Pediatric Surgery,Social Sciences,Sociology,Social Research,