This module applies user-centered, reproducible, and accessible design choices to maximize adoption in resource-constrained settings.
Design for Extreme Accessibility in Low Resource Settings[edit | edit source]
This module applies user-centered, reproducible, and accessible design choices to maximize adoption in resource-constrained settings.
User-Centered Design[edit | edit source]
Medical officers are fully trained, non-specialist physicians who have not received any exposure to orthopedic surgery outside of their undergraduate medical education. Surgeons who are not orthopedic specialists have received formal advanced training in their surgical specialty but have not been trained to perform external fixation procedures for tibial fracture patients.
The placement of an external fixator is one of the 44 essential surgical procedures identified by the World Bank. This module teaches modular external fixation because this procedure offers the greatest freedom in fracture management and maximum patient safety when performed by practitioners who are not orthopedic specialists in resource-constrained settings. The advantages of training non-orthopedic specialists to perform modular external fixation over uniplanar external fixation are that modular external fixationː
- is the preferred method for the temporary stabilization of open tibial fractures
- requires less experience and surgical skill
- permits the practitioner to freely place pins at suitable sites to avoid nerves, vessels, and traumatized soft tissues
- does not require intraoperative X-rays and,
- allows for subsequent definitive fixation.
Medical officers in low-resource settings may not have access to direct fluoroscopy. Modular external fixation of an open tibial fracture is a procedure that can be quickly applied without image intensification and adjusted afterwards.
Practitioners in resource-constrained settings may not have access to orthopedic surgical drills for training. This module recommends a cost-saving ISO 13485 compliant orthopedic surgical drill that is designed for LMICs and permits back-to-back surgeries with a single power drill.
Learners require access to high quality, standardized simulators and training. This module gives surgical practitioners in LMICs access to open-source, affordable, high fidelity, locally reproducible 3D printed bone simulation models for both basic and advanced training that are comparable to state-of-the-art, quality-tested artificial bone products that are available in high income countries.
Learners need access to safe simulation training. All of the 3D printed bone models have a vise attachment to allow the user to secure the model inside a standard vise clamp to maximize learner safety during simulation training. Learners will be obtaining vise clamps locally and these devices can vary in size. We increased the height of the vise attachment of the Tibial Shaft Transverse Fracture Simulator to 6.0 cm in order to maximize compatibility with different sizes of locally available vise clamps.
Based on our user testing, we removed the Far Cortex Breakthrough Detection entirely from the module and chose not to include the Plunge Depth Measurement for the Tibial Shaft Transverse Fracture Simulator. The rationale for these design choices is becauseː
- the likelihood of perforating the far cortex and plunging is very low with the manual advancement of the Schanz screw into the far cortex
- the transparent cellophane allows the learner to visually inspect and confirm that the self-drilling Schanz screws did not perforate the far cortex
- plunge detection has not been shown to confer long-term learning benefits in reducing plunge
- we want to avoid fostering dependence on augmented feedback ("anti-skills") since the learner will not have augmented feedback during the actual procedure, and
- this increases simulator fidelity, reduces simulator costs, simplifies the simulator build, and minimizes simulator assembly time for the learner.
Medical officers and surgeons who are not orthopedic specialists in LMICs have busy work schedules and typically do not have a technical background. We tailored the design of the surgical training module prototype to meet their training needs by:
- Providing high fidelity 3D printed bone models for both basic and advanced simulation training that are designed to substantially simplify the simulator build, minimize the simulator assembly time, and accelerate the learning process for greater convenience for the learner
- Adding detailed instructions on how to input the customized settings for the 3D printed bone models into a 3D slicing program in case the user was not familiar with using advanced 3D slicer settings, and
- Designing the Tibial Shaft Simulator and Tibial Shaft Transverse Fracture Simulator to be easy and quick to assemble and not require any tools, specialized equipment, technical expertise, or time-consuming preparation to build, install, operate and maintain these simulators within the intended place of use.
Over 4 billion people do not have access to the Internet. The penetration of high-speed Internet connectivity (broadband, 3G, or better mobile connections) is less than 30% in rural regions. In 2020, only 46% of the population in sub Saharan Africa owned a mobile phone and smartphones made up only 48% of total mobile connections in sub Saharan Africa. In 2021, nearly 711 million people were in extreme poverty, which is defined as living on less than $1.90 per day. To promote adoption of this surgical training module in low resource settings, we:
- Designed the non-3D printed simulator components to be made using low cost, locally available materials and supplies
- Switched to using cost-saving modelling clay for the backstop instead of single-use foam material for plunge depth measurement on the Tibial Shaft Simulator because clay is reusable and can be locally obtained in LMICs
- Developed an Appropedia module which does not require the downloading of a mobile app, creation of an account, inputting of a username and password, or paying journal or other subscription fees to access the training content
- Provided step-by-step instructions and labelled images (instead of only videos) and published our self-assessment frameworks directly in Appropedia so the module content can be available in multiple languages and exported for offline access
- Created self-assessment frameworks that only require taking photos and not videos which allows learners to use any cellphone with a camera and not only smartphones.
Reproducible Design[edit | edit source]
3D printing technology empowers the local, reliable, and automated manufacturing of high fidelity bone simulation models to permit high quality, standardized simulation training around the world. All of the module's bone simulation model files and print settings are open-source and available on Appropedia, can be locally reproduced on open-source, open filament desktop 3D printers using low-cost, biorenewable plastic, and are designed to be ready for use right out of the 3D printer. These high fidelity 3D printed bone models are designed to substantially simplify the simulator build, minimize the simulator assembly time, and accelerate the learning process for greater convenience for the learner.
On-site access to a 3D printer is not required for the learner. Only one 3D printer is required within a country. The open-source 3D files can be emailed to any 3D printing organization anywhere. The 3D printed simulation models can be picked up by the learner or delivered anywhere across the country by motorcycles, all-terrain vehicles, trucks, or airplanes within 1-2 days.
This module does not require access to teachers, animal bones, artificial bones or human cadaveric bones, and uses locally available hardware and materials, and locally made, high fidelity bone simulation models for bicortical drilling skills and modular external fixation procedure skills training.
When possible, the surgical hardware and equipment are reusable to minimize the use of consumables and maximize their lifespan in the place of use.
The primary risk to reproducibility of this surgical training module is access to affordable orthopedic surgical hardware for training. We have developed local and international partnerships to deliver modular external fixation kits, and surgical drills with autoclavable covers on demand and at minimal cost for up to 82,055 medical officers and surgeons across Nigeria who are not orthopedic specialists.
The total cost of Tibial Shaft Transverse Fracture Simulator consumables per learner is $19.45 USD. The total cost of purchasing the additional reusable supplies in Nigeria for the Tibial Shaft Transverse Fracture Simulator for Modular External Fixation for an Open Tibial Shaft Transverse Fracture Training is $56.40 USD. This Tibial Shaft Transverse Fracture Simulator cost calculation does not cover shipping, delivery or orthopedic surgical hardware, supplies, and equipment costs.
|2021 Learner Costs for Supplies Locally Purchased in Nigeria for the Tibial Shaft Transverse Fracture Simulator for Modular External Fixation for an Open Tibial Shaft Transverse Fracture Training||Item||Quantity||Purchase Cost in USD||Consumable or Resuable|
|3D Printed Adult Male Tibial Bone Model #2 (manufactured locally by a 3D printing company in Nigeria)||1||$9.35 (includes filament, 3D printing, and staffing costs)||Consumable but can be reused indefinitely after hardware removal for a planned module on the Management of Non-Displaced Fractures|
|3D Printed Adult Male Tibial Bone Model #3 (manufactured locally by a 3D printing company in Nigeria)||1||$9.30 (includes filament, 3D printing, and staffing costs)||Consumable but can be reused indefinitely after hardware removal for a planned module on the Management of Non-Displaced Fractures|
|Additional Vise Clamp||1 G-clamp and 1 vise clamp||$54.00||Reusable|
|Cellophane||One 40.0 cm by 100.0 cm strip||$0.80||Consumable|
|Cellphone Camera||1||Readily available in place of use||Reusable|
The total cost of Tibial Shaft Simulator consumables per learner is $9.73 USD. The total cost of purchasing reusable supplies in Nigeria for the Tibial Shaft Simulator for Bicortical Drilling Skills Training is $81.60 USD with the Far Cortex Breakthrough Detector and $60.00 USD without the Far Cortex Breakthrough Detector. This Tibial Shaft Simulator cost calculation does not cover shipping, delivery or orthopedic surgical hardware, supplies, and equipment costs.
|2021 Learner Costs for Supplies Locally Purchased in Nigeria for the Tibial Shaft Simulator for Bicortical Drilling Skills Training||Item||Quantity||Purchase Cost in USD||Consumable or Resuable|
|3D Printed Adult Male Tibial Bone Model #1 (manufactured locally by a 3D printing company in Nigeria)||1||$8.90 (includes filament, 3D printing, and staffing costs)||Consumable|
|Vise Clamp||1 G-clamp and 1 vise clamp||$54.00||Reusable|
|Shallow Container||1||Readily available in place of use||Reusable|
|Aluminum Foil||17.0 cm by 3.0 cm strip||$0.03 (one 30.0 cm x 10.0 m roll of aluminum foil costs $19.20)||Consumable|
|Ruler||1||Readily available in place of use||Reusable|
|Marker||1||Readily available in place of use||Reusable|
|Scissors||1||Readily available in place of use||Reusable|
|Tape||Multiple strips||Readily available in place of use||Consumable|
|Optionalː Wire Stripper||1||Not used; estimated cost is $10.67||Reusable|
|9 V Battery||1||Covered above||Reusable|
|Small Gauge, Non-Insulated Wire||Short length (~12.0 cm or less)||Covered above||Reusable|
|Cellophane||Two 20.0 cm by 100.0 cm strips||$0.80 (one 30.0 cm x 20.0 m roll costs $12.00)||Consumable|
|Modelling Clay||1 block||$6.00||Reusable|
No tools, specialized equipment, technical expertise, or time-consuming preparation is required to build, install, operate and maintain the Tibial Shaft Simulator and Tibial Shaft Transverse Fracture Simulator within the intended place of use.
Our high fidelity simulators offer significant value for money in comparison to existing approaches such as artificial bones and human cadaveric bones.
The costs of the 3D Printed Adult Tibial Bone Models will vary depending on the region's 3D printing organizations, and locally available brands of filament.
In Canada, a 1.0 kg roll of white PLA costs $17.95 CAD which is equal to about 1.4¢ USD per gram. The Tibial Shaft Simulator (3D Printed Adult Female Tibial Bone Model #1) weighs 138.57 grams and the total filament cost in Canada is $1.95 USD. The Tibial Shaft Transverse Fracture Simulator (3D Printed Adult Female Tibial Bone Models # 2 and # 3) weighs 332.86 grams and the total filament cost in Canada is $4.69 USD.
In Nigeria, the 3D printer filament costs for the Tibial Shaft Simulator is $6.88 USD or less and the estimated print time is 6 hours and 2 minutes. The benefits of 3D printing the Tibial Shaft Simulator (3D Printed Adult Female Tibial Bone Models #1) locally in Nigeria for bicortical drilling skills training are that the 3D printer filament costs are 12 times cheaper and the production time is 84 times faster than purchasing a comparable artificial bone cylinder product that is imported from abroad. By obtaining locally made 3D printed bone models for bicortical drilling skills training, the learner also supports the local economy while saving on customs dues, processing fees, and international shipping costs that would be incurred when using artificial bone products that are not made locally.
In Nigeria, the 3D printer filament costs for the Tibial Shaft Transverse Fracture Simulator is $16.53 USD or less and the estimated print time is 15 hours 8 minutes (when the 3D Printed Adult Female Tibial Bone Models #2 and #3 are printed consecutively). The benefits of 3D printing the Tibial Shaft Transverse Fracture Simulator locally in Nigeria for modular external fixation skills training are that the 3D printer filament costs are over 3 times cheaper and the production time is over 33 times faster than purchasing comparable artificial bone products that are imported from abroad, and the 3D printing filament costs are over 9 times cheaper than acquiring a human cadaveric tibia prepared by a local university anatomy lab. By obtaining locally made 3D printed bone models for modular external fixation skills training, the learner also supports the local economy while saving on customs dues, processing fees, and international shipping costs that would be incurred when using artificial bone products that are not made locally.
Accessible Design[edit | edit source]
This Appropedia-based module is available in the 6 official languages of the United Nations, Kiswahili, the lingua franca of the East African Community, and 126 other languages to help ensure that surgical practitioners from anywhere in the world will be able to engage with the content without barriers or gatekeeping.
Each 3D printed bone simulation model displays the model number translated in the 6 official languages of the United Nations, and the model gender using internationally recognized ISO 7001 graphical symbols for males and females to assist with model identification.
We provided step-by-step instructions and labelled images (instead of only videos) so the module content can be available in multiple languages and exported for offline access.
We published our self-assessment frameworks directly in the Appropedia module (instead of a downloadable pdf) to provide automatic translations of the Training Logbooks in multiple languages to learners around the world.
We created self-assessment frameworks that only require taking photos and not videos which allows learners to use any cellphone with a camera and not only smartphones.
This module does not require the downloading of a mobile app, creation of an account, inputting of a username and password, or paying journal or other subscription fees to access the training content.
Offline and Off Grid Access[edit | edit source]
Self-directed training is typically only available online or via mobile apps. These traditional approaches have accessibility barriers in low resource settings because:
- Over 4 billion people do not have access to the Internet
- The penetration of high-speed Internet connectivity (broadband, 3G, or better mobile connections) is less than 30% in rural regions
- Only 46% of the population in sub Saharan Africa owns a mobile phone
- Smartphones make up only 48% of total mobile connections in sub Saharan Africa, and
- An estimated 770 million people worldwide lack access to electricity and 600 million of these individuals reside in sub Saharan Africa.
The demand for this module will be greatest in regions with little or no access to the Internet, smartphones, or grid electricity. Our self-assessment frameworks only require taking photos and not videos. This allows learners to use any cellphone with a camera and not only smartphones. When possible, we have provided images (instead of only videos) so the module content can be available in pdf format using Appropedia's export function for offline access.
Over 235 million people require humanitarian assistance and 44.7 million people in conflict zones lack access to basic medical care. Every day, hospitals, patients, healthcare staff, ambulances, and aid workers come under attack in regions affected by conflict and other emergencies. Online platforms and mobile phones are vulnerable to security breaches which can be used to target bombing attacks on hospitals in conflict zones. It is critical that this training module be available offline to remain isolated from any surveillance from an external Internet connection to prevent hackers from targeting healthcare workers and facilities in conflict zones.
Paper-based versions of surgical training modules are sub-optimal because they cannot provide video and multimedia content which is essential for self-assessed surgical skills training. We can use Linux open-source software and an offline (air gapped), energy-efficient, ultraportable Raspberry Pi with integrated 7-inch touchscreen display to make this module safely available to the surgical practitioners serving the 4 billion people who do not have access to the Internet and the millions of the most vulnerable civilians in conflict zones.
A 2015 study shows that a Raspberry Pi ($35 USD) with a 10 inch display consumes almost the same amount of energy (21.24 kJ/h) as a smartphone ($400 USD) with 4.7 inch display (18 kJ/h), 4.2 times less energy than a $320 USD tablet (90 kJ/h), and 8.5 times less energy than a $728 USD laptop (180 kJ/h). The advantages of using a Raspberry Pi with an integrated 7-inch display screen over a smartphone or tablet are reduced costs, energy efficiency and a larger screen area to optimize learning.
To minimize the use of offline storage capacity and maximize the number of validated, open-source GSTC Appropedia modules that can be stored and made available offline on a Raspberry Pi, we designed this module to minimize the number of secondary or tertiary links, when possible. Our team will be recruiting volunteer Medical Makers to help make GSTC Appropedia modules available offline to maximize the global impact of the GSTC.
Last Mile Implementation[edit | edit source]
We will be partnering with local Makerspaces in LMICs to serve as training, manufacturing, and distribution centers that educate local Makers to make high fidelity, 3D printed bone models and offline simulation training modules at the lowest cost for practitioners in LMICs.
Over half of Nigeria's population of 206 million people live in rural areas but only 15% of the road networks are paved. We are continuing to develop local and international partnerships to deliver locally made 3D printed bone models, modular external fixation kits for simulation training and clinical use, surgical drills with autoclavable covers, and offline training modules on demand and at minimal cost for up to 82,055 medical officers and surgeons across Nigeria who are not orthopedic specialists.
Sustainable Design for Scale-Up[edit | edit source]
We designed our entire module to be available on Appropedia because this platform does not require any subscription fees to maintain our online module and does not require mobile app software development updates to maintain compatibility with future versions of iOS and Android operating systems.
On October 21, 2022, the Department of Orthopedic Surgery at the National Hospital of Abuja completed their accreditation review for the West African College of Surgeons (WACS) and the new guidelines recommend that junior residents be trained to perform external fixation in rural hospitals during their postings. As well, our Team Lead has proposed the topic of "Advances in Simulation-Based Training for Enhanced Trauma Surgical Skills in West Africa" for the WACS Conference and it has been attracting attention (seconded by 3 orthopedic surgeons) on the forum since it was posted 48 hours ago.
In partnership with FabCare, our team co-led a Fab Fest workshop on October 17, 2022 (World Trauma Day) to empower 2,000 Fab Labs in 149 countries to: (i) generate revenue by locally reproducing all GSTC simulators, and (ii) set up reusable simulator equipment lending libraries to advance sustainable surgical education and care in austere settings. Our discussion with workshop attendees from Columbia, Germany, and Japan with backgrounds in military engineering, sustainability, design, and firefighting generated the following ideas:
- Import 3D printer filament and 3D printed bone models from China to help meet market volume needs;
- Bone models can be tailored to the average tibial length and cortical thickness of the learner's local patient population by rescaling the models and changing the wall thickness settings in the Ultimaker Cura slicer program to published bone morphometry values for the target population; and
- Return the used bone models to makerspaces with filament recycling capabilities so the bone models can be converted into printer filament and upcycled into useful objects.
On October 6, 2022, our team gave a presentation about our module to potential donors, civil servants, and educators at the October 6, 2022 Ontario Science Center RBC Innovators Ball and hosted a demonstration booth showcasing our 3D printed surgical simulators afterwards.
On March 5, 2022, our Team Co-Lead gave a keynote presentation for the Women in Leadership Summit 2022 for the Alberta Teachers' Association. We explained how our team has designed open-source, locally reproducible, data-driven, gender-specific, eco-friendly, hygienic, and cruelty-free 3D printed bone models to train healthcare practitioners to develop essential orthopedic surgical skills to prevent needless suffering, disability and deaths for the estimated 133 million people who sustain extremity and pelvic fractures globally every year.
We have submitted an application for a new Guinness World Records title for "Most users to take an online surgical simulation lesson in 24 hours." If accepted by Guinness World Records, this title can be used for all the GSTC modules and can foster collaboration with all GSTC teams moving forward. If our title proposal is not accepted, we can still collaborate with all GSTC teams to set a Guinness World Record for the existing title of "Most users to take an online health awareness lesson in 24 hours."
We plan to host the first annually recurring Guinness World Record-setting event at the National Hospital of Abuja with a hybrid in-person/online global event on Global Surgery Day on May 25, 2023 or another suitable date. A Guinness World Record-setting event will engage learners globally by leveraging the social phenomenon of "fear of missing out" (FOMO). A hybrid in-person/online event will permit learners to participate remotely if they cannot travel to an in-person event.
For greater convenience for learners, our team has offered to host our current and future open-access GSTC modules for residents, and attending physicians in high income countries who wish to learn lifesaving surgical skills. A portion of the proceeds from the workshop fees would be used to help subsidize the costs of the training consumables and hardware for clinical use for learners in resource-constrained settings. During the workshop, learners in high income countries can virtually meet the learners in low to middle income countries who will be benefiting from the workshop fees. We can show the world how physicians in the Global North and South can work together to achieve sustainable and scalable access to GSTC modules in resource-constrained settings.
We have prepared a Charity Sponsor agreement with the Royal College of Surgeons in Ireland (RCSI), with the support of our RCSI mentor, Mr. Eric O'Flynn. Our Charity Sponsor Agreement is intended to receive, administer, and distribute our Global Surgical Training Challenge Team project's funds and non-cash gifts from donors in Canada, U.S. and Ireland and issue tax-deductible receipts to these donors to the extent permitted by law.
To grow community engagement, we are identifying GSTC ambassadors and creating GSTC-themed swag similar to the Stop the Bleed Project. On October 5, 2022, we proposed sharing friendship pins with GSTC Team members, learners and conference attendees who stop by the booth exhibiting the GSTC modules. These lapel pins reflect the diverse GSTC modules and can be worn on a physician's white lab coat or suit jacket.
- A tibia, humerus, and forearm-themed pins represents the Tibial Fracture Fixation, Humeral Fracture Fixation and Pediatric Distal Forearm Fractures Modules
- A blood-themed pin represents the CrashSavers Module
- An uterus or ovum-themed pin represents the ALL-SAFE Module
- A skin-themed pin represents the Z-Plasty Module
- A rectum, colon, and intestine-themed pins represent the Colostomy in Newborns Module
- An appendix-themed pin represents the AMPATH Module
- A cervix-themed pin represents the STARS - Cervical Cancer Screening and Treatment Module
I Heart Guts also has vagina-themed and trachea-themed pins for our planned future modules on Obstetric Fistula Repair and Surgical Cricothyrotomy. I Heart Guts created a special edition Megacolon plush toy for the Mutter Museum. We can spearhead the development of innovative, special edition plush toys, pins, and other merchandise in partnership with a charitable organization to qualify for wholesale pricing, and have the proceeds support our learners in resource-constrained settings.
We can partner with Appropedia and Intersurgeon to also set up a Craigslist-style "needs request" platform to match individual learners who face challenges accessing materials and equipment for our modules with potential donors, stakeholders, and collaborators. We can spearhead the user-centered design of a barrier-free online platform to empower private-public partnerships that are vital for the global scale-up of GSTC modules.
Acknowledgements[edit | edit source]
This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.
References[edit | edit source]
- ↑ Debas, H. T., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock, editors. 2015. Essential Surgery. Disease Control Priorities, third edition, volume 1. Washington, DC: World Bank. doi:10.1596/978-1-4648 -0346-8. License: Creative Commons Attribution CC BY 3.0 IGO.
- ↑ 2.0 2.1 White R. Simple Fracture, Transverse [Internet]. Trafton P, editor. AO Foundation; [cited 2021 Nov 28]. Available from: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-transverse.
- ↑ 3.0 3.1 3.2 Arbutus Medical. Hex Drill Kit - Orthopedic Surgical Drill [Internet]. Arbutus Medical. Arbutus Medical; 2021 [cited 2021 Nov 28]. Available from: https://arbutusmedical.com/drillcover-hex/.
- ↑ 4.0 4.1 Cylinder 40 mm OD x 6 mm wall, hollow, fourth generation [Internet]. Best Anatomical Medical Training Models Company. Sawbones; [cited 2021 Nov 28]. Available from: https://www.sawbones.com/cylinder-40mm-od-w-6mm-wall-length-500mm-4th-gen-composite3403-7.html.
- ↑ 5.0 5.1 Sawbones. Tibia, Plastic Cortical Shell, Large - SKU:1104-9. [Internet]. Vashon, (WA): Sawbones; [cited 2021 Aug 26]. Available from: https://www.sawbones.com/tibia-large-left-solid-white-plastic-no-canal-1104-9.html.
- ↑ Khokhotva M, Backstein D, Dubrowski A. Outcome errors are not necessary for learning orthopedic bone drilling. Can J Surg. 2009 Apr;52(2):98-102. PMID: 19399203; PMCID: PMC2663499. URL: https://pubmed.ncbi.nlm.nih.gov/19399203/.
- ↑ Wierinck E, Puttemans V, Swinnen S, van Steenberghe D. Effect of augmented visual feedback from a virtual reality simulation system on manual dexterity training. Eur J Dent Educ. 2005 Feb;9(1):10-6. doi: 10.1111/j.1600-0579.2004.00351.x. PMID: 15642018.
- ↑ 8.0 8.1 Internet for All: A Framework for Accelerating Internet Access and Adoption (White Paper). World Economic Forum, 12 May 2016. URL: https://www.weforum.org/reports/internet-for all-a-framework-for-accelerating-internet-access-and-adoption.
- ↑ 9.0 9.1 International Telecommunication Union (ITU), 2015, ICT Facts & Figures URL: https://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2015.pdf.
- ↑ 10.0 10.1 https://www.gsma.com/mobileeconomy/wp-content/uploads/2021/09/GSMA_ME_SSA_2021_English_Web_Singles.pdf
- ↑ 11.0 11.1 The Mobile Economy: Sub-Saharan Africa 2020. GSM Association. URL: https://www.gsma.com/mobileeconomy/wp-content/uploads/2020/09/GSMA_MobileEconomy2020_SSA_Eng.pdf.
- ↑ Mahler DG, Yonzan N, Lakner C, Aguilar RAC, Wu H. Updated Estimates of the Impact of Covid-19 on Global Poverty: turning the corner on the pandemic in 2021? [Internet]. World Bank Blogs. 2021 [cited 2021 Dec 10]. Available from: https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-poverty-turning-corner-pandemic-2021.
- ↑ Prusa J. Open-Source 3D printers from Josef Prusa [Internet]. Prusa3D. 2019 [cited 2021 July 29]. Available from: https://www.prusa3d.com/.
- ↑ Ultimaker. Ultimaker 3D printers: Reliable and easy to use [Internet]. ultimaker.com. [cited 2021 July 29]. Available from: https://ultimaker.com/3d-printers.
- ↑ Werz SM, Zeichner SJ, Berg BI, Zeilhofer HF, Thieringer F. 3D printed surgical simulation models as educational tool by maxillofacial surgeons. Eur J Dent Educ. 2018;22(3):e500–5. https://doi.org/10.1111/eje.12332.
- ↑ Legocki AT, Duffy-Peter A, Scott AR. Benefits and Limitations of Entry-Level 3-Dimensional Printing of Maxillofacial Skeletal Models. JAMA Otolaryngol Head Neck Surg. 2017;143(4):389–394. doi:10.1001/jamaoto.2016.3673
- ↑ Liu, K., Madbouly, S. A., Schrader, J. A., Kessler, M. R., Grewell, D. and Graves, W. R. (2015), Biorenewable polymer composites from tall oil-based polyamide and lignincellulose fiber. J. Appl. Polym. Sci., 132, 42592. doi: 10.1002/app.42592.
- ↑ Mills, C. A.; Navarro, M.; Engel, E.; Martinez, E.; Ginebra, M. P.; Planell, J.; Errachid, A.; Samitier, J. J. Biomed. Mater. Res. A 2006, 76A, 781.
- ↑ Auras, R.; Harte, B.; Selke, S. Macromol. Biosci. 2004, 4, 835.
- ↑ Fargo Additive Manufacturing Equipment 3D, LLC. 3D printers, parts, and filament [Internet]. LulzBot. [cited 2021 July 29]. Available from: https://www.lulzbot.com/.
- ↑ 21.0 21.1 21.2 21.3 21.4 AIGE Limited. 3D printers. [Internet]. 3D Printers | AIGE Limited. [cited 2021 July 29]. Available from: https://www.aige.info/3d-printers.
- ↑ 22.0 22.1 22.2 Riders for Health. Medical supply chain logistics. [Internet]. Olney (MD): Riders for Health II; 2021 [cited 2021 Aug 17]. Available from: https://www.riders.org/how-we-work/services/distribution-of-pharmaceuticals-and-medical-supplies/.
- ↑ 23.0 23.1 National Hospital records high patronage on knee, hip replacement surgeries. (2020, January 26) The Sun Nigeria. Retrieved November 11, 2020 from https://www.sunnewsonline.com/national-hospital-records-high-patronage-on-knee-hip-replacement-surgeries/.
- ↑ 24.0 24.1 https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
- ↑ 25.0 25.1 https://data.worldbank.org/indicator/SP.POP.TOTL
- ↑ Filaments.ca. Value PLA 4043D Filament - White - 1.75mm - 1KG [Internet]. Filaments.ca. 2021 [cited 2021 Dec 10]. Available from: https://filaments.ca/collections/3d-filaments/products/value-pla-filament-white-1-75mm.
- ↑ 27.0 27.1 Kuunda 3D Ltd. Personal communication. July 14, 2021.
- ↑ Dr. Habila Umaru. Personal communication. May 13, 2021.
- ↑ https://en.wikipedia.org/wiki/Google_Translate
- ↑ IEA (2018), Population without access to electricity falls below 1 billion, IEA, Paris https://www.iea.org/commentaries/population-without-access-to-electricity-falls-below-1- billion.
- ↑ United Nations Office for the Coordination of Humanitarian Affairs. Global Humanitarian Overview 2021. [Internet]. Geneva (Switzerland): United Nations Office for the Coordination of Humanitarian Affairs; 25 November 2020 [cited 2021 Aug 17]. Available from: https://gho.unocha.org/.
- ↑ Creating Hope in Conflict: A Humanitarian Grand Challenge - Request for Proposals February 19, 2018.
- ↑ International Committee of the Red Cross. Why we can't save her life | On The Frontline. [Internet]. San Bruno (CA): Youtube; 2018 May 3 [cited 2021 Aug 27]. Available from: https://www.youtube.com/watch?v=wm0TYebjyHQ.
- ↑ International Red Cross and Red Crescent Movement. HCID Initiative: A global initiative. [Internet]. Geneva (Switzerland): International Red Cross and Red Crescent Movement; 2018 [cited 2021 Aug 27]. Available from: https://healthcareindanger.org/hcid-project/.
- ↑ Fish I. My computer was hacked so Russian warplanes could bomb underground hospital in Syria, claims surgeon who carried out remote surgery in Aleppo. [Internet]. London (UK): The Daily Mail; 2018 March 21 [revised 2018 Mar 21; cited 2021 Aug 17]. Available from: https://www.dailymail.co.uk/news/article-5525391/British-surgeons-computer-hacked-Syrian-hospital.html.
- ↑ Raspberry Pi. Teach, learn, and make with Raspberry Pi [Internet]. Cambridge (UK): Raspberry Pi; 2021 [cited 2021 Aug 18]. Available from: https://www.raspberrypi.org/.
- ↑ Raspberry Pi. Buy a Raspberry Pi Touch Display [Internet]. Cambridge (UK): Raspberry Pi; 2021 [cited 2021 Aug 18]. Available from: https://www.raspberrypi.org/products/raspberry-pi-touch-display/.
- ↑ Anwaar W, Shah MA. Energy Efficient Computing: A Comparison of Raspberry PI with Modern Devices. International Journal of Computer and Information Technology. 2015 Mar;4(2):410-413.
- ↑ https://www.fablabs.io/labs/map
- ↑ https://impacthub.net/about-us-regions-locations/
- ↑ https://wiki.hackerspaces.org/List_of_Hacker_Spaces
- ↑ https://makerspaces.make.co/
- ↑ https://www.riders.org/where-we-work/nigeria/
- ↑ External Fixation [Internet]. Orthopaedics International. [cited 2021 Nov 28]. Available from: https://orthopaedicsinternational.org/solutions/external-fixation/.
- ↑ https://iheartguts.com/blogs/i-heart-guts/14704041-colon-meets-colon