The Implementation of Simulation-Based Learning for Training Undergraduate Medical Students in Essential Surgical Care Across Sub-Saharan Africa: a Scoping Review

Abstract

Much surgery in sub-Saharan Africa is provided by non-specialists who lack postgraduate surgical training. These can benefit from simulation-based learning (SBL) for essential surgery. Whilst SBL in high-income contexts, and for training surgical specialists, has been explored, SBL for surgical training during undergraduate medical education needs to be better defined. From 26 studies, we identify gaps in application of simulation to African undergraduate surgical education, including lack of published SBL for most (65%) World Bank–defined essential operations. Most SBL is recent (2017–2021), unsustained, occurs in Eastern Africa (78%), and can be enriched by improving content, participant spread, and collaborations.

Introduction

The 2015 Lancet Commission on Global Surgery highlighted a massive shortfall in global surgical capacity particularly concentrated in low- and middle-income countries (LMICs), with 5 billion people lacking access to surgical care globally. Despite a large burden of surgical disease in sub-Saharan Africa (SSA), there is a grossly inadequate number of surgery, anaesthesia, and obstetric (SAO) providers which is more marked in rural areas [1]. Unlike their counterparts in high-income countries (HICs) who need to undertake residency training before engaging in independent surgical practice, medical school graduates in SSA perform essential surgical procedures within their first year after graduation (Fig. 1).

Fig. 1.

Pathways to independent surgical practice in selected countries. An asterisk denotes no undergraduate pre-medical training required. Note that independent surgical practice is possible in SSA without specialty training, and the effectiveness of simulation-based learning (SBL) does not differ for countries that have different pathways to independent surgical practice

At the district hospital level, these general practitioners perform caesarean sections, laparotomies, and reduction of open fractures [2]. For example, in rural Rwanda, up to 90% of caesarean sections and 50% of abdominal emergencies are performed by general practitioners [3, 4]. This raises the need for surgically competent and entrustable medical school graduates. Building this competence is challenging, in view of the insufficient number of trainers, the relatively large number of medical students, prioritization of postgraduate surgical trainees at the expense of medical students, and the heavy workload of surgeons who might find it difficult to dedicate intraoperative time to teaching [5]. In addition, ethical dilemmas arise around permitting students to perform surgery, especially under often inadequate levels of senior supervision [6–8]. Simulation-based surgical training may present a solution for some of these challenges [9]. Exploration of how surgical simulation has been used, and the description of types of World Bank essential surgical procedures taught using surgical simulation in undergraduate education may guide the process of contextualizing the use of effective low-cost, high-impact simulation in sub-Saharan Africa.

In simulation, real-life surgical encounters are modelled in a controlled setting in order to help students achieve specific clinical educational goals. Surgical simulation ‘involves the use of objects, devices, electronic and/or mechanical surgical simulators, cadavers, animals, and animal organs to reproduce or represent, under test conditions, situations that are likely to occur in actual performance’ [10] These are being increasingly utilized in medical training in HICs. The spectrum of realism or authenticity varies along a simulation ‘fidelity’ continuum, which is a subject of recent debate, as perceptions of fidelity vary widely based on its mediation of sensory perceptions, the task demands, learning objectives, the environment, and factors suspending disbelief [11]. Its use ranges from low- to high-fidelity, based upon the degree to which the simulator attempts to replicate ‘real life’ situations or experiences for the learner. There is increasing evidence supporting the superiority of even low-fidelity SBL over historically utilized, more didactic teaching methods when undertaking training of procedural skills such as surgical suturing and central line insertion [12–14]. Furthermore, there is also an expanding evidence base suggesting its value in developing rigorous, context specific, non-technical skills for surgery [15, 16] which have been shown to be important for improving the safety and quality of surgical care [17, 18]. Multiple techniques for SBL for surgery include bench top models which can be synthetic models (rubber, silicone, polyurethane, latex skin pads, microfoam tape, or styrofoam), organic models (fruits and vegetables like bananas or oranges), and ex vivo animal tissue models (cow skin, ox tongue, pig skin, chicken skin, chicken wings or breast, etc.) [10, 19]. Others include live animal models under anaesthesia, which can be either purchased or stray animals in some contexts, cadaveric models, virtual, augmented, or mixed reality models, and hybrid simulators [10, 19]. Specialized SBL for newer technologies are also in use [19].

SBL is now very widely used in postgraduate surgical training, and its value in undergraduate medical training in high-income countries is also well recognized [20]. However, the use of simulation for undergraduate training in surgery in SSA is yet to be explored, despite its potential to address challenges faced by essential surgical training in context [21]. SBL has immense potential to prepare students for essential surgeries at the primary health centre and district hospital as identified by the World Bank Disease Control Priorities [22], such as caesarean section, reduction of fractures, and laparotomy. Collaborations between engineers and medical educators, such as those highlighted by the American College of Surgeons and the American Society of Engineers, have contributed to highlighting a ‘Three-Way Partnership between Physicians, Technology, and Information to Improve Patient Care’ that contributes to conceptualization, design, and execution of SBL, largely in high-income countries [23].

Identification of the training gap in essential surgical skills will enlighten the scope of collaboration needed for SSA to meet the pressing need for safe and effective scale up of surgical services in the world’s most underserved populations. The aims of this scoping review were to identify geographical and educational gaps in simulation use in undergraduate medical training, and to highlight potential areas for collaboration between engineering and medical experts, ranging from the conception, design, improvisation, and promotion of SBL across SSA. It should, however, be noted that the issues addressed by this paper are not exclusive to Africa or SSA countries but are shared by other LMIC country settings.

Methods

Eligibility Criteria

We performed a scoping review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [24]. Screening inclusion and exclusion criteria were agreed upon within the authorship team prior to title and abstract screening, full text review, and extraction stages using a documented but unregistered scoping review protocol. Our inclusion criteria encompassed any original research or reviews reporting data on the use of SBL in undergraduate training and education specific to surgical clerkships, programs or procedures, or surgical internship training in SSA. We also included articles describing training for students studying primarily in SSA exposed to international training programs as part of their program. Our definition of undergraduate surgical training broadly encompassed training of nursing, medical, or dental students undertaking their first degree or its equivalent in the provision of operative, perioperative, or non-operative management of surgical and/or obstetric condition(s) including the provision of anaesthesia care.

We excluded studies concerning undergraduate simulation training programs not related to surgery and those focused on surgical training outside of SSA. Articles not connected with surgical training, focused on postgraduate residency or fellowship training, not utilizing simulation, and those from high-income settings were excluded. Opinion pieces or editorials were also excluded.

Search Method

Initial broad search terms including ‘simulation’, ‘medical education’, ‘surgery’, and ‘Sub-Saharan Africa’ were defined. A comprehensive search strategy was developed. PubMed, Embase, and African Index Medicus databases were searched systematically on 30th August 2021 with no time or language restrictions. The full search strategy applied is provided in as an open-access search string [25]. The final literature search was updated in August 2023.

We also identified additional relevant publications by citation reviews and through consultation with expert members of the authorship team who were immersed in undergraduate medical SBL in various SSA contexts.

Selection of Sources of Evidence

Covidence systematic review software [26] was used to facilitate paper screening at both title and abstract, and full text review stages, and Zotero reference manager [27] was used to remove duplicate texts. BA, PK, and CF performed title and abstract review. Three members of the research team (BA, FW, OM) used Microsoft Excel software to manually extract data. Full text review was undertaken by BA and PK. Extraction was undertaken by both BA and FW with any conflicts resolved through consensus with OM.

Data Abstraction

The variables selected for abstraction were identified a priori via authorship consensus and the resulting data charting form was developed by BA and reviewed by RR prior to commencing data extraction. Variables included the list of authors, title, study reference, year published, journal, open-access status, study methodology, sample size, location of study, target group, specific skills taught, outcomes, and conclusions. The inclusion of specific non-technical skills, the level of the trainees, specialty in which learners were trained, specifics of the tutors, the tutor to participant ratio, the male to female ratio of trainees, trainee recruitment method, year of study, type of simulation, fidelity of simulation, and specific name of simulator used were also included in the abstraction form a priori. The authors also decided a priori to collect data on course duration, whether the SBL was on an existing curriculum or just newly introduced to the program or trialed with the study, whether the SBL was planned as a one-off or a recurring training, and whether there were any collaborations involved in SBL delivery.

Data Analysis and Grading of Evidence

Analysis was done by frequencies and percentages. The Medical Education Research Study Quality Instrument (MERSQI) scores for each paper (possible total range 5–18) were assessed primarily to determine the quality of the educational research of papers included in this review and not to exclude sources of evidence, as this is a scoping review (Table 1) [28, 29]. Domains assessed included study design, sampling, type of data, validity of evaluation instrument, data analysis, and outcomes.

Table 1.

Summary of 26 studies included in scoping review

Study	Title	Year	Country	Target group	Skills taught	Inclusion of non-technical skills	Simulation fidelity	Specialty	The Medical Education Research Study Quality Instrument (MERSQI) score*
Adeyemi-Doro 1983 [30]	A new course in basic therapeutic skills for medical and dental students at the College of Medicine, University of Lagos: student evaluation	1983	Nigeria	Medical and dental students	Suturing of skin lacerations, Incision and drainage of abscesses, cardiopulmonary resuscitation, reduction of temporomandibular joint dislocation, eyelet jaw wiring, inferior dental regional nerve block	No	Low fidelity	General surgery	Study design (SD) = 2; sampling (S) = 2; type of data (TD) = 3; validity of instrument (VI) = 1; data analysis (DA) = 2; outcomes (O) = 1.5 Total = 11.5
Bedada 2022 [31]	Surgical Simulation Training for Medical Students: Strategies and Implications in Botswana	2022	Botswana	Medical students	Simple interrupted suture, laparoscopic peg transfer, laparoscopic intracorporeal suture	No	Dry lab, low fidelity	General surgery (laparoscopic surgery)	SD = 2 S = 2 TD = 3 VI = 3 DA = 3 O = 1.5 Total = 14.5
Bekele 2019 [32]	Trends in Retention and Decay of Basic Surgical Skills: Evidence from Addis Ababa University, Ethiopia: A Prospective Case–Control Cohort Study	2019	Ethiopia	Medical students	Identification of surgical instruments, simple interrupted suturing and one-handed knot tying, intestinal skills such as perforation repair and anastomosis, abdominal wall incision and closure, catheterization, chest tube insertion, and basics of airway management	No	Wet, dry, low fidelity	General surgery	SD = 3 S = 2 TD = 3 VI = 2 DA = 3 O = 1.5 Total = 14.5
Bulamba 2019 [33]	Feasibility of Simulation-Based Medical Education in a Low-Income Country: Challenges and Solutions From a 3-year Pilot Program in Uganda	2019	Uganda	Bachelor of Science in Anaesthesia program, clinical year medical students	Basic and advanced life support, advanced trauma management course, non-specific medical student simulation for clinical years	No	High and low fidelity	Anaesthesia, obstetrics/gynaecology, trauma, orthopaedics, and general surgery	SD = 1 S = 1 TD = 1 VI = 0 DA = 2 O = 1 Total = 6
Data 2020 [34]	Feasibility of an Interprofessional, Simulation-Based Curriculum to Improve Teamwork Skills, Clinical Skills, and Knowledge of Undergraduate Medical and Nursing Students in Uganda: A Cohort Study	2020	Uganda	Medical and nursing students	Management of postpartum haemorrhage for obstetrics postoperative bleeding for surgery	No	High fidelity	General surgery, obstetrics/gynaecology	SD = 2 S = 2 TD = 3 VI = 2 DA = 3 O = 1.5 Total = 13.5
Dery 2019 [35]	Design and evaluation of a subcutaneous contraceptive implant training simulator	2019	Ghana	Undergraduate nursing students	Insertion of subcutaneous contraceptive implants	No	High fidelity	Obstetrics/gynaecology; general surgery	SD = 1 S = 0.5 TD = 3 VI = 2 DA = 3 O = 1.5 Total = 11
Elharram 2017 [36]	Global Health Values of a Multidirectional Near Peer Training Program in Surgery, Pathology, Anatomy, Research Methodology, and Medical Education for Haitian, Rwandan, and Canadian Medical Students	2017	Held in Canada invited Haiti, Rwanda	Medical students	Suturing and knot tying, orthopaedic casting and splinting, and Foley catheter and nasogastric tube insertion	No	High and low fidelity	General surgery	SD = 1 S = 2 TD = 1 VI = 1 DA = 2 O = 1 Total = 8
Ezeaka 2022 [21]	Perspectives of medical students on simulation-based training: the Nigerian experience	2022	Nigeria	Medical students	Basic life support (BLS), online BLS	No	High and low fidelity	Paediatrics	SD = 1 S = 2 TD = 1 VI = 1 DA = 3 O = 1 Total = 9
Gedlu 2015 [37]	Introduction of simulation based medical education at Addis Ababa University College Of Health Sciences: experience and challenge	2015	Ethiopia	Clinical educators for undergrad teaching and medical students		No	Low fidelity	Unspecified	SD = 1.5 S = 2 TD = 1 VI = 2 DA = 3 O = 1 Total = 10.5
Hey 2023 [38]	Developing a Surgical Simulation Curriculum for the Rwandan Context	2023	Rwanda	Medical students	Basic surgical skills, Informed consent WHO safety checklist Patient positioning Patient draping Introduction to knot tying Venous access (peripheral and central) Introduction to surgical instruments Interactive ATLS, FAST, drainage of superficial abscess Wound debridement and drainage Excision and biopsy of a cutaneous lesion, endotracheal intubation Local anaesthesia Introduction to suturing Passing of nasogastric tubes, rectal examinations and proctoscopy, breast biopsy, urethral and suprapubic catheterization, Splinting and plaster of paris application, head trauma, burn patient assessment and management	No	High and low fidelity	General surgery	SD = 1 S = 0.5 TD = 1 VI = 0 DA = 2 O = 1 Total = 5.5
Hey 2023 [39]	Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda	2023	Rwanda	Medical students	Core needle breast biopsy	No	Dry lab, low fidelity	General (breast surgery)	SD = 1.5 S = 2 TD = 1 VI = 2 DA = 2 O = 1 Total = 9.5
Kirsch 2023 [40]	GlobalSurgBox: A Portable Surgical Simulator for Surgical Trainees Worldwide	2023	Kenya, Rwanda and USA	Medical students	Two-handed square knots, one-handed square knots, basic suturing, instrument ties	No	Low fidelity	General, cardiothoracic	SD = 1 S = 3 TD = 1 VI = 1 DA = 3 O = 1 Total = 10
Makkink 2019 [41]	For the students, by the students: Student perceptions of low cost medical moulage in a resource-constrained environment	2019	South Africa	Bachelor’s degree in Emergency Medical Care	Wound care	No	Low fidelity (moulage)	Emergency medical care	SD = 1 S = 1.5 TD = 1 VI = 2 DA = 2 O = 1 Total = 8.5
Murthy 2020 [42]	A Randomized Cross-Over Trial Focused on Clinical Breast Exam Skill Acquisition Using High Fidelity versus Low Fidelity Simulation Models in Rwanda	2020	Rwanda	Medical students	Clinical breast examination	No	High and low fidelity	General surgery	SD = 3 S = 2 TD = 3 VI = 3 DA = 3 O = 1.5 Total = 15.5
Najjuma 2020 [43]	Stakeholder perceptions about the establishment of medical simulation-based learning at a university in a low resource setting: a qualitative study in Uganda	2020	Uganda	Students enrolled in the Bachelor of Medicine and Surgery, and Bachelor of Nursing Science	Assessing factors that will affect formation of a simulation centre	No	Not described	Surgery (unspecified), obstetrics, and gynaecology	SD =  S =  TD =  VI =  DA =  O =  Total = 9.5
Owolabi 2021 [44]	Implementation of Innovative Educational Technologies in Teaching of Anatomy and Basic Medical Sciences During the COVID-19 Pandemic in a Developing Country: The COVID-19 Silver Lining?	2021	Rwanda	Pre-clinical med students	Haemorrhage control, intravenous access, intubation, and basic intensive care–integrated curriculum	No	High fidelity	Surgery, obstetrics/gynaecology, emergency medical care	SD = 1 S = 0.5 TD = 1 VI = 0 DA = 2 O = 1 Total = 5.5
Owolabi 2022 [45]	A Study of Anatomy Teachers’ Perception and Acceptance of the Anatomage Table Technology and Digital Teaching Materials in the Training of Medical and Allied Health Students	2022	Rwanda	Medical students	Non-specific ‘surgical skills’	No	High fidelity	General surgery	SD = 1 S = 2 TD = 1 VI = 0 DA = 1 O = 1 Total = 6
Peluso 2017 [46]	Strengthening medical training programmes by focusing on professional transitions: a national bridging programme to prepare medical school graduates for their role as medical interns in Botswana	2017	Botswana	Just after medical school, pre-internship	Surgical skills workshop, management of epistaxis, polytrauma, plaster application, evaluation and management of surgical wounds, suturing, knot tying	No	Not described	General surgery	SD = 1.5 S = 2 TD = 1 VI = 2 DA = 2 O = 1.5 Total = 10
Ravi 2021 [47]	Undergraduate Surgical Education: a Global Perspective	2021							SD = 2 S = 1.5 TD = 3 VI = 0 DA = 2 O = 1 Total = 9.5
			Kenya	Medical students	Student societies organize structured courses on basic surgical skills	No	Not described	General surgery
			Somaliland	Medical students	Student societies, in partnership with international societies (e.g. InciSioN, International Association of Student Surgical Societies), organize conferences and short courses which cover topics such as suturing, sterilization, and the WHO surgical safety checklist	No	Not described	General surgery
Saad 1991 [48]	An oral practical examination in emergency clinical surgery	1991	Sudan	Final year medical students	Emergency surgery and traumatology assessment. A third of aggregate marks	No	Low fidelity	General surgery and traumatology	SD = 1 S = 2 TD = 1 VI = 0 DA = 2 O = 1 Total = 7
Taché 2009 [49]	Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania	2009	Tanzania	Medical students	Scrubbing, gowning, gloving, patient preparation, surgical knot tying, venous cutdown, adult intubation, chest tube insertion, laparotomy, small bowel repair, vacuum-assisted vaginal delivery	No	Dry lab, high and low fidelity	General surgery, orthopaedics, anaesthesia, and obstetrics/gynaecology	SD = 1.5 S = 1.5 TD = 3 VI = 2 DA = 3 O = 1.5 Total = 12.5
Takoutsing 2023 [50]	Assessing the impact of neurosurgery and neuroanatomy simulation using 3D non-cadaveric models amongst selected African medical students	2023	Cameroon	Medical students	Craniotomy (neurosurgery)	No	High fidelity	Neurosurgery	SD = 1 S = 2 TD = 1 VI = 2 DA = 1 O = 1 Total = 9
Tjoflåt 2017 [51]	Implementing simulation in a nursing education programme: a case report from Tanzania	2017	Tanzania	Ordinary Diploma Program in Nursing	Primary survey, implementing relevant nursing interventions and working as a team, postoperative care	Yes	Low fidelity	Nursing	SD = 1 S = 1 TD = 1 VI = 0 DA = 2 O = 1 Total = 6
Turatsinze 2020 [52]	Medical student satisfaction and confidence in simulation-based learning in Rwanda—Pre and post-simulation survey research	2020	Rwanda	Medical students	Paediatric procedures — relevant to paediatric surgery ABCDE clinical assessment, interosseus insertion, intravenous access, inter-professional communication skills, decision-making, time management, patient safety and prescribing, all in a protected environment. Inter-professional communication skills were taught using the situations, background, assessment, and recommendation (SBAR) method	Yes	Low fidelity	Paediatrics	SD = 1.5 S = 1.5 TD = 3 VI = 2 DA = 3 O = 1.5 Total = 12.5
Ullrich 2020 [53]	Design, implementation and long-term follow-up of a context specific trauma training course in Uganda: Lessons learned and future directions	2020	Uganda	Interns, just after medical school	Primary, secondary, tertiary survey, and application of plaster of paris, basic life support, burr hole procedure, venous cut down, chest drainage	No	Low fidelity	General surgery	SD = 2 S = 1 TD = 3 VI = 2 DA = 2 O = 2 Total = 13
Wanjiku [54]	Assessing the impact of an emergency trauma course for senior medical students in Kenya	2017	Kenya	Medical students	Cricothyroidotomy, intravenous access, tube thoracostomy, extended-focused assessment sonography for trauma, scenarios include closed head injury requiring intubation, blunt abdominal trauma in a pregnant woman, gunshot wound to the right chest, and blunt abdominal trauma from a motorcycle accident	Yes	Low fidelity	Surgery (not specified)	SD = 1.5 S = 1 TD = 3 VI = 0 DA = 3 O = 1.5 Total = 10

Values in bold indicate the total MERSQI score

SD study design, S sampling, TD type of data, VI validity of instrument, DA data analysis, O outcomes, Total total MERSQI score ranging from 5 to 18

*MERSQI score has been reported by components

Results

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Fig. 2).

Fig. 2.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram [24]

Initial database searches in August 2021 returned 116 articles of which 10 were duplicate records. The search was updated in August 2023 with a total of 180 articles identified with 33 duplicates. One-hundred and twenty-two articles were excluded through both title and abstract screening, and full text review. One additional paper was identified through expert consultation which resulted in a total of 26 papers being exported for review. All 26 papers have been included in the final data extraction, analysis, and reporting process (Table 1) [21, 30–54].

Across 26 of the studies evaluating published research on SBL in undergraduate surgical education, the median MERSQI score was 9.75 (range 5.5–15.5, out of a possible total score of 18).

Studies that met the inclusion criteria were conducted across a range of 11 countries in SSA. Based on African Union regions, East Africa hosted 73.1% (n = 19) of the referenced programs in contrast to Central Africa, which had only 1 documented undergraduate surgical SBL program (Fig. 3). West and Southern Africa hosted only 11.5% (n = 3) each. In one study, simulation education for undergraduate surgical education was held in Canada for students of a Rwandan medical school as part of a multi-country educational program. Most of these simulation programs (84.6%, n = 22) were only recently introduced (from 2017 through 2023). Only 1 article was identified from the 1980s and another in the 1990s [30, 48].

Fig. 3.

Geographical distribution of studies on undergraduate surgical simulation–based learning in sub-Saharan Africa. Created with mapchart.net

Programs targeted various undergraduate learners, including medical students (73.1%, n = 19), nursing students (15.4%, n = 4), dental students (3.8%, n = 1), pre-interns (7.7%, n = 2), emergency medical care students (3.8%, n = 1), and undergraduate anaesthesia students (3.8%, n = 1). Up to 15.4% (n = 4) of the simulation use could be considered multi-disciplinary, including medical, nursing, and/or dental school students within the same program. Most surgical SBL was targeted at senior clinical students — only one in five programs documented its use within the first half of undergraduate training. Up to 52.4% (n = 11/21) of the documented simulation programs were newly introduced at the time they were being studied. Only 42.3% (n = 11) were planned as sustained, recurring programs.

About half (46.2%, n = 12) of the included programs explicitly utilized low-fidelity models, and 23.1% (n = 6) utilized a combination of both high- and low-fidelity modalities within the same program, whilst 19.2% (n = 5) utilized high-fidelity models only for training. Fidelity was largely reported by the programs, but were also classified by authors in the absence of fidelity self-reports.

Simulation programs were predominantly directed by general surgery teams (61.5%, n = 16). The most commonly taught technical skills were acute resuscitation including cardiopulmonary resuscitation (30.8%, n = 8), suturing of lacerations (30.8%, n = 8), surgical knot tying (23.1%, n = 6), airway management (23.1%, n = 6), orthopaedic application of fracture casts (21.1%, n = 5), and chest tube insertion (15.4%, n = 4) (Table 2). Whilst all programs included at least some aspect of surgical technical skills training, 11.5% also formally addressed non-technical skills, including teamwork, inter-professional communication skills, decision-making, and time management. Only 7 of the 26 studies (27%) objectively assessed effectiveness through skills gain [31, 32, 34, 35, 42, 49, 54] which ranged from a mean difference of 2.3%, with no statistically significant difference following SBL [34], to 76.1% (p < 0.001) [32]. Average mean difference in pre- and post SBL skill scores from data in these studies was 42.9% [31, 32, 34, 35, 42, 49, 54]. All 7 studies showed positive mean difference in pre- and post SBL assessments; however, 2 studies found a positive mean difference in pre- and post SBL assessments without statistically significant difference [34, 35].

Table 2.

Topics covered in SSA simulation programs by specific region

Simulation topics (N = 78)	n	Study references	Region(s)	%
Resuscitation and airway management
Airway management (basics of airway management, intubation, cricothyroidotomy)	6	[32, 38, 49, 52–54]	East Africa	5.5
Resuscitation (primary, secondary, tertiary survey, BLS, CPR)	8	[21, 30, 38, 48, 51–54]	West/East Africa	7.3
Surgical procedures
Surgical preparation
Surgical equipment sterilization	1	[47]	East Africa	0.9
Scrubbing	1	[49]	East Africa	0.9
Gowning	1	[49]	East Africa	0.9
Gloving	1	[49]	East Africa	0.9
Surgical knot tying	6	[32, 36, 38, 40, 46, 47]	South/East Africa	5.5
Patient positioning	1	[38]	East Africa	0.9
Patient draping	1	[38]	East Africa	0.9
Patient skin preparation	1	[49]	East Africa	0.9
General surgical procedures
Suturing of skin lacerations	8	[30–32, 36, 39, 40, 46, 47]	West/East/South Africa	7.3
Incision and drainage of abscesses	2	[30, 38]	West/East Africa	1.8
Laparotomy/abdominal access and closure	2	[32, 49]	East Africa	1.8
Intestinal perforation repair/anastomosis	3	[32, 49, 52]	East Africa	2.7
Haemorrhage control	3	[34, 46, 48]	South/East Africa	2.7
Management of epistaxis	1	[46]	Southern Africa	0.9
Wound debridement	1	[38]	East Africa	0.9
Excision biopsy for skin lesions	1	[38]	East Africa	0.9
Core needle breast biopsy	2	[38, 39]	East Africa	1.8
Proctoscopy	1	[38]	East Africa	0.9
Laparoscopic surgery	1	[31]	South Africa	0.9
Neurosurgery procedures
Burr hole	1	[53]	East Africa	0.9
Craniotomy	1	[50]	Central Africa	0.9
Cardiothoracic surgery procedures
Chest tube insertion	4	[32, 49, 53, 54]	East Africa	3.6
Anaesthesia procedures
Administration of local anaesthesia	1	[38]	East Africa	0.9
Inferior dental regional nerve block	1	[30]	West Africa	0.9
Orthopaedics procedures
Orthopaedic casting	5	[36, 38, 46, 48, 53]	South/East Africa	4.5
Orthopaedic splinting	2	[36, 38]	East Africa	1.8
Dental/oro-maxillofacial surgery procedures
Reduction of temporomandibular joint dislocation	1	[30]	West Africa	0.9
Eyelet jaw wiring	1	[30]	West Africa	0.9
Obstetric-gynaecologic procedures
Vacuum-assisted vaginal delivery	1	[49]	East Africa	0.9
Insertions of subcutaneous contraceptive implants	1	[35]	West Africa	0.9
Trauma
Management of polytrauma	1	[46]	Southern Africa	0.9
Focused assessment sonography for trauma (or extended)	2	[38, 54]	East Africa	1.8
Urology procedures
Suprapubic cystostomy	1	[38]	East Africa	0.9
Venous access
Venous cutdown	2	[49, 53]	East Africa	1.8
Interosseus insertion	1	[52]	East Africa	0.9
Peripheral intravenous canula placement	3	[38, 52, 54]	East Africa	2.7
Central venous access	1	[38]	East Africa	0.9
Surgical safety and checklists (quality improvement)
WHO surgical safety checklist	2	[38, 47]	East Africa	1.8
Obtaining informed consent	1	[38]	East Africa	0.9
Simulation for nursing procedures
Bladder catheterization (Foley’s)	3	[32, 36, 38]	East Africa	2.7
Wound care	2	[41, 46]	Southern Africa	1.8
Nasogastric tube insertion	2	[36, 38]	East Africa	1.8
General nursing interventions	1	[51]	East Africa	0.9
Postoperative care	1	[51]	East Africa	0.9
Clinical examinations
Clinical breast examination	1	[42]	East Africa	0.9
Digital rectal examination	1	[38]	East Africa	0.9
Clinical scenarios
Head injury (closed/requiring intubation)	2	[38, 54]	East Africa	1.8
Blunt abdominal trauma in a pregnant woman	1	[54]	East Africa	0.9
Gunshot wound to the right chest	1	[54]	East Africa	0.9
Burn patient assessment and management	1	[38]	East Africa	0.9
Thematic simulation
Traumatology	1	[48]	East Africa	0.9
Emergency surgery	1	[48]	East Africa	0.9
Non-technical skills
Team work	1	[51]	East Africa	0.9
Inter-professional communication skills	1	[52]	East Africa	0.9
Decision-making	1	[52]	East Africa	0.9
Time management	1	[52]	East Africa	0.9
Patient safety and prescribing	1	[52]	East Africa	0.9
Others
Surgical instrument identification	2	[32, 38]	East Africa	1.8

Next, we mapped the surgical skills taught via simulation onto the list of essential surgical procedures for the primary health centre (PHC) and first-level (i.e. district general/rural) hospital, as defined by the World Bank Disease Control Priority Program (DCP3) (Table 3). Simulation was utilized in the training for five (55.6%) of the nine essential surgical procedures identified at PHC level. Only nine (32.1%) of the 28 procedures required at first-level hospitals were taught using SBL. Only 3 of the 26 programs (11.5%) had specific collaborations between engineers and physicians for the conception, design, or execution of SBL.

Table 3.

Overlap between essential surgical procedures and simulation-based learning for undergraduate learners in sub-Saharan Africa

List of WHO/World Bank Disease Control Priorities (DCP3) essential surgical care procedures	Procedures taught using simulation-based learning (SBL) in sub-Saharan Africa (SSA)a		Number of educational programs identified that are using SBL to teach these procedures
	Yes/no	n (%)
Expected essential procedures at primary health centre level (N = 9)		n = 5/9 (55.6%) for essential procedures at primary care level
1. Dental extraction	No
2. Drainage of dental abscess	No
3. Treatment of dental caries	No
4. Normal (spontaneous vaginal) delivery	Yes		1
5. Drainage of a superficial abscess	Yes		2
6. Male circumcision	No
7. Resuscitation with basic life support measures	Yes		8
8. Suturing laceration	Yes		8
9. Management of non-displaced fractures	Yes		6
Expected essential procedures at first level/district general hospital level (N = 28)		n = 10/28 (35.7%) for essential procedures at first (district) care level
1. Caesarean birth	No
2. Vacuum extraction/forceps delivery	Yes		1
3. Ectopic pregnancy	No
4. Manual vacuum aspiration and dilatation and curettage	No
5. Tubal ligation	No
6. Vasectomy	No
7. Hysterectomy for uterine rupture or intractable postpartum haemorrhage	No
8. Visual inspection with acetic acid and cryotherapy for precancerous cervical lesions	No
9. Repair of perforations: for example, perforated peptic ulcer, typhoid ileal perforation	Yes		3
10. Appendectomy	No
11. Bowel obstruction	No
12. Colostomy	No
13. Gallbladder disease, including emergency surgery	No
14. Hernia, including incarceration	No
15. Hydrocelectomy	No
16. Relief of urinary obstruction: catheterization or suprapubic cystostomy	Yes		3
17. Resuscitation with advanced life support measures, including surgical airway	Yes		11
18. Tube thoracostomy (chest drain)	Yes		4
19. Trauma laparotomy	Yes		2
20. Fracture reduction	Yes		5
21. Irrigation and debridement of open fractures	Yes		1
22. Placement of external fixator; use of traction	Yes		1
23. Escharotomy/fasciotomy (cutting of constricting tissue to relieve pressure from swelling)	No
24. Trauma-related amputations	No
25. Skin grafting	No
26. Burr hole	Yes		1
27. Drainage of septic arthritis	No
28. Debridement of osteomyelitis	No

^aNo procedures at second- or third-level hospitals (including repair of obstetric fistula, cleft lip, cleft palate, anorectal malformations, Hirschsprung’s disease, and club foot, shunts for hydrocephalus, surgery for visual impairment, cataract extraction and insertion of intraocular lens, and eyelid surgery for trachoma) were taught to medical undergraduates using simulation-based learning

Discussion

There is a limited body of evidence available to guide the curricula of this modality of training for undergraduate medical education in SSA. Therefore, it is important to document, for the first time, the gaps and potential as identified in literature. Despite the recognized benefits of SBL in medical education, reports documenting its effectiveness for skill gain in SSA are occasional, with mean difference in skill assessments ranging from 2.3 to 76.1%. There appears to be a skew in documentation of SBL in undergraduate education towards Eastern Africa, with only one report from Central Africa, and limited use in Western and Southern Africa. A higher prevalence of HIC/LMIC partnerships (with the associated funding and expertise) in Eastern Africa were evident in this review [32, 34, 36, 37, 42, 51, 54]. There is potential for a more widespread impact of simulation on training of surgical personnel to meet the needs of SSA by leveraging relationships between academic, medical, and engineering institutions with medical and other health professional schools in LMICs. Emphasis should be on expanding partnerships to Central, West, and Southern Africa for more equitable exposure of learners to the opportunities of hands-on SBL in a safe space. However, it is possible that programs are being run, but reports are not being published in literature for multiple reasons, including insufficient funding, inequitable access to publication options, and language barriers. Our findings of limited reports on simulation for undergraduate training are in contrast with findings in other LMIC contexts in Asia including Thailand, where 83% of instructors from 16 medical schools across the country use SBL in their classes [55]; India [56]; and China, where reports of highly complex simulation for undergraduate teaching have been documented [57].

Recently graduated doctors in SSA perform basic surgical procedures earlier in their careers compared to many HIC trained doctors. These procedures are often performed independently or with minimal supervision in their role as district hospital general practitioners (Fig. 1). The WHO DCP3 lists 44 essential surgical procedures as a baseline for meeting the currently unmet needs of communities across LMICs. This list is further broken down into procedures that should be performed in tertiary hospitals (n = 44), level 1 or district/general hospitals (n = 37), and primary health centres (n = 9). Only a small proportion of these essential procedures are being taught using SBL, and this highlights untapped potential for improving the breadth and quality of surgical training of medical and nursing graduates in SSA. Surgical simulation training should be expanded in order to increase the efficiency of healthcare training in essential procedures.

A reliable barometer of a healthcare systems’ ability to provide safe and effective access to surgical care is measured through the three ‘Bellwether’ procedures (caesarean section, emergency laparotomy, and open fracture reduction and fixation). In rural Rwanda, up to 97% of caesarean sections are performed independently by general practitioners [58]. The shortfall in SOA specialist providers and large burden of surgical disease as well as inequity in rural–urban distribution of surgical professionals raises the need to produce ‘surgery-ready’ medical graduates in SSA. However, from our review, no medical schools provided documented simulation training in emergency caesarean sections. Only a few identified programs simulated open fracture management and emergency laparotomy. This highlights a missed training opportunity in undergraduate medical education in SSA. Using SBL to train doctors in the Bellwether procedures can help scale access to essential surgical services in the region. Effectiveness of simulation-based learning in undergraduate medical education is focused on skill gain [54, 59]. There is need for wider study and in-depth assessment of the efficiency of specific types of SBL to objectively address surgical skill areas for undergraduates in SSA through objective structured assessments, beyond perceptions of skill or knowledge gain [59]. Beyond a scoping review, future systematic reviews and meta-analysis should truly answer the question of effectiveness of SBL in teaching specific surgical skills for this context [60].

Very few programs (11.5%) included in this review had interdisciplinary engineering-medical teams working together to produce simulation programs. This could be because most simulations were on established, basic simulators. Limitations of local engineering capacity, a disconnect between medicine and engineering, or funding shortfalls amongst other factors may have also contributed. Taking the simulation agenda forward in SSA, the intersectoral and transdisciplinary nature of simulation has to be emphasized. The advantages of grassroots trans-sectoral engagement include the availability of more professional expertise for the design, maintenance, and deployment of simulation education. The emphasis of this engagement however should not be to shift the simulation modes to high-fidelity, high-cost simulation models which are non-sustainable for the SSA context, but to find creative ways to produce high-yield, low-cost simulation that will improve practice.

The sustainability of simulation programs in SSA is a concern that must be carefully considered with these partnerships. Most SBL documented at this level of medical training was captured at the start of the program. The programs appeared to be largely initiated for research, and were predominantly new or starting at the time of documentation. Creative funding, local ownership, concerted capacity building, and equitable partnerships will encourage these programs to continue beyond available grant funding. Follow-up studies may be in order to track the progress of these programs and assess their current state.

Effective non-technical skills (NTS) amongst both medical and nursing staff are increasingly recognized as a vital aspect of the provision of safe surgery. It has been shown that errors in surgical decision-making contribute to almost half of errors made in the operating room [61]. Despite this, only 11.5% of identified programs taught NTS alongside technical skills. Incorporating this can potentially help reduce errors in the operating theatre [62, 63]. Whilst the importance of NTS in surgery is increasingly reflected in the provision of specific training courses in SSA, these courses are generally provided to qualified and practicing operating theatre staff [64]. There is also limited published evidence regarding the use of simulation in teaching NTS, with a recent systematic review of NTS training in LMICs identifying only 2 of 21 publications that discussed the use of simulation programs for NTS training [65]. SBL lends itself well to combining both technical skills and NTS training in variable resource contexts such as SSA, where it has been argued that non-technical skills play a more significant role in the provision of safe and effective surgical care [66]. We believe it would be valuable to utilize a combined approach during the early stages of medical education. Expanding the use of SBL in SSA to teach and train undergraduate medical and nursing students will undoubtedly be a valuable future endeavour in the attempt to effectively scale up access to safe surgery. Furthermore, given the value of low-fidelity simulation in providing effective NTS training this would be a potentially low-cost, easily scalable measure to be explored.

A summarized, pre-consensus list of items a SBL for surgery in SSA seeking to train medical officers in basic World Bank Disease Control Priority surgery at Primary Health Center and District Hospital levels is suggested from our results in Table 4.

Table 4.

Suggested summarized (pre-consensus) list of items needed for SBL for surgery in a low resource SSA context [33, 38, 49]

	Equipment/item	Comments
1	GlobalSurgBox [38, 40]	Knot tying models [49] and suture skin pads are an alternative
2	Trauma mannequin [33, 38]	Neck collar
3	Adult intubation mannequin [38]	Needs laryngoscope, AMBU bag, and endotracheal tubes [38]
4	Cricothyroidotomy model
5	Venous access models [38, 49]	Plastic tube placed on arm stabilizer covered with foam and vinyl or sponges and IV tubing for venous access/cutdown are a low-cost alternative to ready venous access models [49]
6	Tube thoracostomy (chest tube insertion) model [38, 49]	Consider using teaching skeleton rib cage draped with foam and vinyl [49] or goat ribs attached to a cardboard box for chest tube insertion [53]
7	Nasogastric tube insertion models [38]
8	Plaster of paris [38]
9	Dental extraction model	Benchtop model from goat head as an alternative
10	Male circumcision model	Can use a high-fidelity product or repurposed parts from used or donated mannequins and partial-task trainers. A student actor/standardized patient can replace this need [33]
11	Moulage for burns and wounds simulation [41]
12	3D printer [50]
13	Clinical breast examination model [38]	High fidelity or low fidelity like the Ineza Rwanda model [42]
14	Breast biopsy model [38, 39]	Jell-o model [38]
15	Digital rectal examination model [38]
16	Abscess models [38]	Filled gloves in sponges for abscess simulation [38]
17	Caesarean section model	Obstetrical mannequin — high or low fidelity
18	Vacuum extraction, delivery forceps for assisted vaginal birth simulation
19	Laparotomy model [38]	Wood frame with foam, clear and coloured vinyl [49], intestinal anastomosis can be demonstrated with GlobalSurgBox, or inner tubes from bicycle tires [49]
20	Manual vacuum aspiration/dilatation and curettage model
21	Urethral catheterization model [38]	Suprapubic cystostomy possible with GlobalSurgBox [38]
22	Debridement model [38]
23	Point of care ultrasound scan [38]
24	Needle and syringe/local anaesthesia bottles
25	Surgical bed for simulation of draping, positioning [33, 38]	Wood bench draped with plastic with abdominal landmarks is a low-cost alternative [49]; most clinical equipment, such as the gurneys, anaesthesia machine, defibrillation unit, airway equipment, intravenous tubing setups, and patient monitor cables can usually be procured cheaply from local medical surplus stores [33]
26	Surgical safety checklists [38]

A limitation of this review is that some articles from journals that are not online or registered with public databases might have been missed. Many journals local to sub-Saharan Africa are not on major databases. We attempted to address this by searching on an Africa-specific database and asking for identification of relevant articles by African simulation experts but are aware that there may be gaps in the identification of non-indexed literature.

Conclusion

The use of SBL for undergraduate surgical training in SSA has been demonstrated in the literature. Reports suggest that it is effective in engendering improved surgical skills in this context. Although simulation remains an effective tool to enhance both technical and non-technical skills for surgical care globally, only about one-third of WHO essential surgical procedures are taught to undergraduates in SSA utilizing simulation, and less than 12% of programs focused on NTS training. Most documentation of surgical SBL identified in this review was focused on East Africa. As engineering and educational partnerships appear to drive the use of simulation in this region, training institutions in West, Central, and Southern Africa could identify such opportunities. In addition, many reports characterized initial stages of program development and implementation. This review highlights an opportunity to improve the scope and quality of surgical care in Africa without the risk of learning potentially risky procedures on clinical patients. Long-term follow-up of feasibility, affordability, and efficacy of these efforts should be considered, and assessing the sustainability of indigenous simulation programs can help cement adoption of SBL in SSA.

Author Contribution

Contributions of authors using the CRediT author statement: Conceptualization: BA, JMR, SY, RRR, AB, Methodology: BA, EA, Formal analysis: BA, CF, OM, PK, Investigation: BA, CF, OM, PK, Validation: BA, CF, OM, PK, FW, RRR, AB, Resources: CF, BA, Writing — original draft: BA, CF, Writing — review and editing: BA, CF, OM, PK, NS, FW, MTH, GSP, EA, JMR, SY, RRR, AB, Visualization: BA, CF, Project administration: BA, PK, MTH, Supervision: EA, JMR, SY, RRR, AB. Robert R. Riviello and Abebe Bekele are co-senior authors.

Funding

There was no funding obtained for this research. Barnabas Alayande is a current Fogarty Global Health Fellow supported by the Fogarty International Center and National Institute of Mental Health, of the National Institutes of Health under Award Number D43 TW010543.

Availability of Data and Materials

All data generated or analysed during this review are included in this published article.

Declarations

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Competing Interests

The authors declare no competing interests.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.