Medical imaging community outreach program: lesson to students and impact to the community

Abstract

Background

The community outreach program is one of the main activities of the University of Rwanda, and both staff and students get involved in this tremendous initiative to serve the community free of charge.

Purpose

The main objectives of this community engagement activity were to raise awareness of medical imaging services and abdominal ultrasound screening.

Methods

The project proposal was planned by the Medical Imaging Department, University of Rwanda College of Medicine and Health Sciences, Remera Campus. It took place at Kigali’s main car park. Two ultrasound machines were used, and screening was done by students under supervision of registered sonographers. A cross-sectional design with random sampling was employed, and SPSS version 21 was used for data analysis. Statistical techniques were used to calculate inter-observer reliability by comparing patient complaints and sonographic diagnosis.

Results

Herein we report the first medical imaging community outreach, on which 86 patients received ultrasound abdominal scans free of charge. Of these, 33 (38.5%) were male and 53 (61.5%) were female. Their ages varied from 20 to 76 years, with a mean age of 48. The screened organs included the liver, gall bladder, pancreas, spleen, kidneys, urinary bladder, prostate, uterus and ovaries, and abnormalities were identified in different organs. The results showed a high degree of reliability between what was presented by the patients and measurements found after diagnosis by the sonographer. The average measure of the intraclass correlation coefficient was 0.973, with 95% confidence intervals ranging from 0.959 to 0.983 (F (85,85) = 37.537, p < 0.001).

Conclusion

This experience was beneficial to the Medical Imaging Sciences Department staff and students, as well as to the Society of Medical Imaging and Radiation in Rwanda. The results showed that this outreach was also very positive for the community at large.

Introduction

Community-based outreach activities are an important aspect of medical imaging sciences education, as they provide learners with a number of benefits including increased confidence, clinical competence and teamwork skills [1]. They also provide health education and health services to the community, especially to disadvantaged groups [2]. Medical imaging services incorporate the technique and process of creating visual representations of the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues [3]. The medical imaging services offered in Rwanda include diagnostic ultrasound, general radiography, dental radiography, CT scan, MRI and radiotherapy, all of which make vital contributions to modern, quality healthcare. Of these imaging modalities, there are only two that do not use ionizing radiations: magnetic resonance imaging (MRI) and ultrasound. In community engagement activities, ultrasound is the most preferred and feasible of the modalities noted, as it is physically simple, easily transportable, mobile, and does not use ionizing radiation [4].

Different studies found that general knowledge of radiation and radiation protection is insufficient among health professions and the public [5]. These facts motivated the Medical Imaging department staff to organize the first community outreach. This took place at Kigali’s main car park, which is located in the Nyarugenge District in Kigali City, on January 30, 2020. The area was chosen for the community-based outreach because it brings together many people coming from Kigali City in Rwanda and from other provinces, as well as those from the neighboring countries. Therefore, the message could reach a large segment of the population. Such activities could not be easily performed before because ultrasound is a new module and was introduced during the upgrading of the curriculum from an advanced diploma to a bachelor’s degree, and because other kinds of imaging equipment are so heavy and largely use ionizing radiation [6, 7]. The main aims of the activity were to raise awareness of medical imaging services and the use of ionizing radiation, as well as to carry out screening of abdominal organs using ultrasound to diagnose communicable and non-communicable diseases which can affect and damage internal organs. In addition, this activity was expected to sensitize the public to the need for early and regular check-ups.

Methodology

A cross-sectional descriptive design was used for the study project, which was planned and carried out by staff and students of the University of Rwanda College of Medicine and Health Sciences in collaboration with the Society of Medical Imaging and Radiation in Rwanda (SMIR) and Medical Imaging Students Association in Rwanda (MISAR). The leaders of Kigali’s main car park played a significant role, and assisted in disseminating the information to the target community two days before the screening. Permission was requested from the local government of Kigali City. Screening and education about medical imaging services took place concurrently. Two rooms were created inside the tents, two ultrasound machines were used, and most patients were scanned by students under the supervision of registered sonographers, lecturers from the Medical Imaging Department/University of Rwanda. Data were analyzed using SPSS Version 21, and descriptive statistics were used to generate findings about the age, sex, and organs of patients, as well as the final diagnoses. The degree of agreement for different diagnostic tests was calculated by determining the Kappa coefficient for inter-observer agreement between frequencies of patient complaints and sonographic diagnosis.

Student and staff involvement

A total of 17 medical imaging sciences students—10 in fourth year, 5 in third year, and 2 in second year—participated in different activities. Students were able to directly experience the appearance of various disease conditions on ultrasound. Fourth, or final, year students were mainly involved in ultrasound screening, while others were involved in health education, informing the community about medical imaging services and protection from ionizing radiation. The Society of Medical Imaging and Radiation in Rwanda (SMIR) was represented by 3 members who assisted in various program activities. Two Medical Imaging Sciences Department lectures registered as sonographers were involved in screening to assist students in getting to the right diagnoses, and three other lectures supervised other logistical processes.

Results

Eighty-six participants were included in this community outreach event. They were chosen according to their arrival time; no special selection criteria were used. Of the participants, 33 (38.5%) were male and 53 (61.5%) female (Fig. 1). The median age was 48.6 years with a relatively normal distribution between 20 and 76 years, and a slight skew towards young ages (Fig. 2). The targeted organs included the liver, gall bladder, pancreas, spleen, kidneys, urinary bladder, prostate, uterus and ovaries (see Table 1). Among 86 participants, 22 (25.5%) had either one or more abnormalities, while 4 were pregnant. Three of these were not aware of their pregnancies, which varied in age between 8 and 37 weeks. Surprisingly, there was a special case of a woman whose pregnancy was at 24 weeks (about 6 months), which she did not realize until the outreach day. She confirmed she had spent a 10-year period with secondary infertility before she conceived. Among the abnormalities seen, 7 (28%) were in the liver, including 3 cases of fatty liver, 2 of cirrhosis (Fig. 3), and 2 cases of liver mass. Two cases (8%) of cholelithiasis (Fig. 4), 1 spleen mass and 1 case of splenomegaly were noted. Two cases of hydronephrosis were also noted. Both were associated with prostate enlargement, and 1 of these cases was associated with advanced urinary bladder diverticulosis. Among 53 female participants, gynecological scans revealed 1 case of echocomplex cyst (Fig. 5), and 6 cases (24% of abnormalities) of simple ovarian cysts (see Table 1). Statistical data analysis shows a high degree of reliability between patients’ complaints and measurements found after diagnosis by the sonographer (see Table 2). The average measure of the intraclass correlation coefficient was 0.973, with a 95% confidence interval ranging from 0.959 to 0.983 (F (85,85) = 37.537, p < 0.001).

Fig. 1.

Sex of participants

Fig. 2.

Distribution of age of participants

Table 1.

Affected organs and Sonographic diagnosis

Variable	Frequency	%
Organ
Liver	7	29.2
Gall bladder	2	8.3
Spleen	2	8.3
Pelvis region	13	54.2
Diagnosis
Cirrhosis	2	2.3
Fatty liver	3	3.5
Liver mass	2	2.3
Cholelithiasis	2	2.3
Splenomegaly	1	1.2
Splenic mass	1	1.2
Prostate hypertrophy with complications	2	2.3
Ovarian simple cyst	6	7.0
Ovarian complex cyst	1	1.2
Pregnancy	4	4.7
Normal	62	72.1

Fig. 3.

Sonographic images of a 50 year old male patient with known chronic hepatitic B virus. a Curvilinear probe showed a coarse liver with ascites. b The same patient in Fig. 5a; linear probe outlined clearly irregularity of liver margins

Fig. 4.

A sonogram of a 48 year old male with right upper quadrant pain showing a single gall stone with acoustic shadowing

Fig. 5.

A sonogram of a 35 years female with chronic right lower quadrant pain showing a large thin walled cystic mass in the right adnexial region compressing the urinary bladder

Table 2.

Interobserver agreement between patients’ complaints and diagnostic tests

	Intraclass correlation	95% confidence interval		F test with true value 0
		Lower bound	Upper bound	Value	df1	df2
Single measures	0.948	0.921	0.966	37.537	85	85
Average measures	0.973	0.959	0.983	37.537	85	85

Discussion

The community outreach activity by the Medical Imaging Sciences Department was made possible through the introduction of an ultrasound module in the curriculum. Other imaging modalities are impractical in such circumstances, as they are heavy and sophisticated, and most of them use ionizing radiations. Ultrasound has become a first-line diagnostic tool for most medical specialties and an important tool for training medical students in anatomy, physiology and pathophysiology. It is believed to increase students’ ability to use the machine, their confidence in the interpretation of results and their inter-specialty collaboration at the same time, making them competent future clinicians [6–8]. The World Federation of Ultrasound in Medicine and Biology (WFUMB) and the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) have also recommended that hands-on experience be a major part of ultrasound training, and have stated that the quality of ultrasound training delivered to students is determined by the type of ultrasound equipment available, the educational approach selected and faculty skill sets [6, 7, 9, 10]. Different researchers and ultrasound associations/federations have confirmed that ultrasound teaching is skill-based and requires enough hands-on, practical sessions to allow learners to understand clinical scenarios and be familiar with sonographic patterns of diseases [6–10]. The mentioned federations and other researchers discourage the use of ultrasound without proper training [11]. The Medical Imaging Sciences Department at University of Rwanda has incorporated ultrasound teaching into the undergraduate Bachelor of Medical Imaging Sciences curriculum to respond to high market demand and to the shortage of radiologists in the country. In addition to classic teaching methods, another learning approach which has shown great benefits for students is community outreach [12]. Students are exposed to different clinical cases of varying indications, and this prepares them to fit in their future careers, as has been reported in other previous studies [6, 7, 13]. The findings from this survey show that the liver and ovaries were the most commonly affected organs, which is quite different from the results found in Japan where the screening of abdominal organs revealed renal cancers as the most common problem in the abdomen [14]. This report demonstrates that a large portion of the population have unknown disease conditions. Of the patients screened, 25.5% were found to have at least one disease condition, and 5% of the women had previously unknown pregnancies. Strategies for management of their conditions were communicated to participants. This is similar to what was reported by other researchers in previous studies [12]. In addition to screening activities, education about medical imaging services and radiation protection was carried out successfully. Despite these achievements, the community showed a great need for these screening activities, and the number of available ultrasound machines did not satisfy the demand. The execution of ultrasound teaching necessitates proper preparation as well as resources [6, 7]. Further community-based outreach activities need to be organized in the department, as well as at other schools and colleges that have incorporated ultrasound modules into their curricula. The WHO states that two thirds of the world has no access to medical imaging services. Due to the fact that ultrasound is the simplest, and is free of ionizing radiation, it is possible to bring it to every corner of the world [8]. It is the duty of academic institutions to train competent end users to improve patient management, and stakeholders are encouraged to facilitate these activities. This kind of training has been regarded as one of the active learning methods that help learners to achieve educational objectives [15].

Conclusion

The community outreach event in Kigali City involved many people in all different activities. Students in the field were allowed to extend their skills by working on different clinical cases, which is different from on-campus training where simulated patients and hypothetical cases are used. Furthermore, the Medical Imaging Department raised awareness of its existence and its contribution to the medical field, and the community benefited from free ultrasound screening and health education. Community outreach is a very important aspect of the medical imaging technologist education. On the basis of this community outreach, ultrasound was found to be a very important imaging modality that can easily be used in screening activities. It can help the population to know the status of their life, as the researchers saw when some abnormalities and unknown advanced pregnancy cases were identified. For further engagement, it will be very helpful to know whether the number of ultrasound machines increases, as this can improve the outreach outcomes.

Abbreviations

MRI

Magnetic resonance Imaging

UR-CMHS

University of Rwanda-College of Medicine and Health Sciences

SMIR

Society of Medical Imaging and Radiation in Rwanda

MISAR

Medical Imaging Students Association in Rwanda

SPSS

Statistical Package for the Social Sciences

WHO

World Health Organization

WFUMB

Word Federation of Ultrasound in Medicine and Biology

EFSUMB

European Federation of Societies for Ultrasound in Medicine and Biology

Author contributions

MT wrote the first draft of the proposal for the management to confirm, coordinated activities at the fields, compiled the manuscript documents, and was responsible for data; KI revised the proposal; BRW worked on methodology; SAJ supervised the screening activities and revised the manuscript; OE revised the manuscript before submission; RR participated in statistical analysis; MM followed up the proposal for approval, overall coordination of outreach activities.

Funding

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Compliance with ethical standards

Conflict of interest

Authors declare that there is no conflict of interest.

Ethics approval and consent to participate

This activity was in line with the attributes of the University of Rwanda as one of the university main activities. This does not go through regular Institutional Review Board rather approved by the College management. Written consents were obtained during the screening activity and it was on voluntary basis.