title: Validation of a community-based survey assessing non-obstetric surgical conditions in Burera District, Rwanda.
abstract: 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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  The Harvard Sheldon Traveling Fellowship.
authors: Georgetown University Hospital, Department of Surgery, Washington, DC, USA; Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA. Electronic address: alli.linden@gmail.com.
authors: Allison F
authors: AF
authors: Linden
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; University of California San Francisco Medical Center, Department of Surgery, San Francisco, CA, USA.
authors: Rebecca
authors: R
authors: Maine
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Partners In Health, Boston, MA, USA.
authors: Bethany L
authors: BL
authors: Hedt-Gauthier
authors: Partners In Health, Boston, MA, USA.
authors: Emmanual
authors: E
authors: Kamanzi
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA.
authors: Gita
authors: G
authors: Mody
authors: University of Rwanda College of Medicine and Health Sciences, Department of Surgery, Kigali, Rwanda.
authors: Georges
authors: G
authors: Ntakiyiruta
authors: Rwanda Military Hospital, Kigali, Rwanda.
authors: Grace
authors: G
authors: Kansayisa
authors: Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda.
authors: Edmond
authors: E
authors: Ntaganda
authors: Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda.
authors: Francine
authors: F
authors: Niyonkuru
authors: Partners In Health, Boston, MA, USA.
authors: Joel
authors: J
authors: Mubiligi
authors: Rwanda Ministry of Health, Butaro Hospital, Kigali, Rwanda.
authors: Tharcisse
authors: T
authors: Mpunga
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Boston Children's Hospital, Department of Plastic and Oral Surgery, Boston, MA, USA.
authors: John G
authors: JG
authors: Meara
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA.
authors: Robert
authors: R
authors: Riviello