International virtual radiation therapy professional development: Reflections on a twinning collaboration between a low/middle and high income country

Abstract

In response to the documented challenges to providing adequate radiotherapy services to its population, the Ethiopian government has embarked on a plan to augment such services. In tandem with the need for the required equipment is the need for qualified staff for its safe operation. Twinning collaborations between low (LIC) and high income countries (HIC) have been proven effective for improving health care services and outcomes. In this short communication, organizers of a virtual professional development program for radiation therapy staff, from Tikur Anbessa Specialized Hospital (Ethiopia, LIC) and Princess Margaret Cancer Centre (Canada, HIC) reflect on the experience and suggest ideas for increasing value and impact.

Background

Ethiopia is a low-income country (LIC) in sub-Saharan Africa home to over 100 million people, the second most populous country in Africa. Atop of the growing population and significant cancer burden, there are numerous other challenges to adequate delivery of radiotherapy (RT) where it is estimated that 70 % of patients would benefit from RT at some point in their disease course [1].

Tikur Anbessa Specialized Hospital (TAS) was established in Addis Ababa, Ethiopia, in 1961 and in 2020, was home to the only linear accelerators in the country, treating over 1,700 patients annually [1]. It is estimated that nearly 80,000 people were diagnosed with cancer in 2022, and 55,000 people died, with these numbers expected to more than double in the next two decades [2]. In response, the Ethiopian government is working to increase capacity with new centers and equipment [3], but the availability of qualified health human resources must keep pace to ensure safe and high quality treatment.

Princess Margaret Cancer Centre (PMCC) is the largest comprehensive cancer care centre in Canada. Its Radiation Medicine Program sees over 8,000 new patients yearly and is home to a rich research and educational culture in partnership with the Department of Radiation Oncology, University of Toronto (UTDRO) [4]. In 2015, representatives of UTDRO travelled to Addis Ababa to investigate educational needs and opportunities in radiation oncology under the umbrella of the Toronto-Addis Ababa Academic Collaboration Agreement (TAAAC), a partnership struck in 2003 between the Universities of Toronto and of Addis Ababa (AAU) [5]. A letter of agreement was signed and discussion of how to collaborate began.

While original talks focused on undergraduate training for radiation therapists at AAU, a number of factors impeded these discussion, which were further hampered by the COVID 19 pandemic. In 2020, in the face of all of these challenges, and based on the motivation of the leadership at TAS to proceed, a virtual training series was proposed to augment previous training (provided by local faculty and vendor) for improved utilization of the new linear accelerator by the radiation therapy (RT) team which required the transition from 2D to 3D RT. Funding for infrastructure was provided from a PM Global Oncology Grant.

Collaborations between LIC and HIC institutions have proven effective in improving oncologic treatment outcomes and are recommended by the World Health Organization [6], specific strategies suggested by Rodin et al [7], and examples of success in these kinds of partnerships published [8], [9]. However, it is difficult to create and sustain such affiliations. In this short communication, we describe one twinning collaboration between TAS and PMCC for the implementation of a virtual professional development (PD) program for the existing RT staff at TAS. Further, we will provide reflections of the experience from both the providers (organizers and faculty from PMCC) and the participants (coordinators and attendees from TAS) involved in the program series.

Project overview

Methods

Two series were delivered in 2020 (pilot project) and 2021/22 (second series) virtually to eight RT staff (two certified radiation therapists and six RT assistants with experience using 2D radiation therapy equipment only) and other staff members as available (radiation oncologist, medical physicist, trainees). Each disease-site section included a collection of recordings, synchronous lectures and case-based discussions, and demonstrations using various RT specific computer-based simulation platforms (VERT^TM, Raystation^TM, EVOQ^TM) to provide education that would prepare the RT team for:

• •Implementation of linear accelerators in clinical practice
• •Implementation of CT simulation practice supporting 3DRT delivery
• •Quality assurance strategies to support of 3D conformal practices

It was important to ensure that the program was culturally situated to respect practice environment and models of care that are in place locally.

An additional goal was to try to develop an educational model that would be scalable and transferable to other regions/programs.

Evaluation

Communication between providers and participants was ongoing during and between each series. Informal feedback was collected in real time and adjustments made as required and possible.

Each live session was evaluated using an 18-item online survey which included questions about the content, the clarity and value of the instruction, impact on practice, as well as practical considerations such as connectivity, ability to ask questions and organization.

For the second series, a pre/post knowledge test was added.

A final focus group was held 18 months after the second series to gather reflections from the participants.

Reflections

This summary is culled from the evaluation data and conversations that took place between providers and participants over the three-year period of developing, implementing and evaluating the series. The summary will highlight the challenges embedded in this kind of intercontinental twinning collaboration as well as suggested improvements through both lenses. While the literature is clear on several expected challenges, such as time zone differences and internet connectivity, both of which we experienced, this reflection piece highlights additional, more subtle challenges and how they are seen by the providers and the participants.

While developing curriculum to meet the needs of the participants was quite concrete (based on needs assessment and case mix of TAS), the actual scheduling of the sessions posed a greater challenge from the outset. After days and times were established for the first series, attendance at the virtual sessions became our first hurdle. While the provider assumed that it was clear that the delivery of a virtual program inferred the requirement for each learner to log in individually, it soon became apparent that that was not possible. First, many participants did not own their own laptops and participating in the virtual sessions was difficult on a handheld device given the detailed nature of content (data, diagrams, images). In addition, finding locations onsite for a group to gather around a computer was difficult. When it could be arranged, a number of participants were required to sit around a single laptop in a meeting room which was not ideal. They often did not have microphones and it was not easy to use the chat function to engage with faculty when there was a large group. For the first series, two of the learners were completing another educational program offsite so were able to log in independently and as such, they dominated the sessions and the discussions. In the second series, the need for participants to have access to spaces adequately equipped for interaction was emphasized and addressed. Even if several had to join together, they could at least speak to us, ask and answer questions.

However, new attendance issues arose in the second series that were unavoidable. In 2021, the TAS RT department moved to shift work; meaning that only half of the staff would be available at any given time within operating hours. To ensure all learners had access to the content, live sessions were recorded and provided to TAS for asynchronous viewing by those who were unable to attend (and for review by live session attendees). However, few attempts were made to view the material offline. Review of the barriers to accessing recordings revealed that a combination of limited time and technological issues accessing the recordings led to low rates of viewing. The technological issues related, at least, to download speed which was deemed easy to address. The issue of time commitment outside of working hours was more complex.

Our second identified hurdle was communication. While electronic communication amongst organizers was excellent during development phases, communication with the participants during the series was more difficult. Largely, the provider used email to communicate with learners (as is common practice for the provider) using email addresses provided at the start of the project. The provider assumed that this was acceptable. However, over time it was discovered that, instead of using email (sharing Zoom links, scheduling updates, links to online surveys), participants were communicating amongst themselves using other platforms. Discussion at the final focus group revealed that Whatsapp^TM is a far more common and acceptable way to communicate amongst work colleagues in Ethiopia. While in North America Whatsapp is usually reserved for informal and personal communication, it is used widely in other parts of the world for professional communication. It was also noted that while employers provide institutional email addresses for their employees, user policies and technological barriers prevent their use from becoming the cultural norm. Staff continue to use their personal emails when communicating externally. These personal email addresses are often limited by storage space and require additional fees to increase the amount of storage, whereas Whatsapp is unlimited. In addition, the ‘ease of use’ of a phone-based, versus computer-based, platform cannot be discounted. It became evident that the use of email as the main mechanism for electronic communication was a factor in low session attendance and low response rate to evaluation surveys.

The experiences from this three-year twinning collaboration have led to several revelations about what works and what doesn’t. It is perceived that the greatest challenge to a successful series is time. Workload and schedules make it impossible for all participants to be present at live sessions held during normal operating hours. The two possible solutions to this problem come with associated challenges. Ways to motivate participants to attend live sessions that fall outside of the normal working day (ie. on a weekend) could be sought, but this isn’t a clear advantage in and of itself, and would prove challenging for the provider in terms of faculty availability and the possible associated cost. The other suggestion is to improve the participants’ willingness and ability to seek arrangements to attend live sessions and to access asynchronous content in between the live sessions and above all, to feel invested in the program.

In order to do this, the collaborators discussed their joint responsibility to build a local culture for appreciating the value of these kinds of educational opportunities, and to find ways to augment participants’ motivation to participate. One of the most promising ideas is to institute a process to award participants, who meet specified criteria, a ‘certificate of completion’ for the educational series. It is hypothesized that instituting such an award for successful completion would go some distance to improving engagement and learning. Several expectations would be connected to the certificate. First, attendance would be tracked. This would require the participants to make the effort to log into the live sessions, be seen, and to have a level of engagement that could be recognized. While the existing barriers may not have disappeared, there would be motivation for the participants interested in a certificate to organize themselves to ensure they meet expectations. Technological issues related to accessing recorded content would need to be resolved with the use of a learning management system (LMS) that wouldn’t require file downloading. The LMS could also track participant engagement with the recordings that would also be tracked for the purposes of certification. Finally, award of the certificate would be connected to the completion of the pre- and post-course knowledge test and the completion of the required lecture and course evaluation forms.

To add weight to the certificate, several aligned initiatives could be instituted. First, admission into the course could be competitive as opposed to open to all. This will force applicants to reflect on the value of the exercise before entering the program and only apply if they intended to be suitably engaged. Second, the local department could agree that certification would be considered heavily in decisions about departmental promotions whether it be for supervisory, educational or other leadership positions. Third, the certificates could be considered a pre-requisite for eligibility for other activities such as conference attendance and/or international educational rotations. Such rotations were included following the second series and felt to be extremely valuable to consolidate learning and to gather ideas for future projects. Finally, credits assigned by the local professional college could contribute to annual PD requirements for participants. It is perceived that these initiatives and opportunities combined would be seen as valued outcomes for investing the time and effort to complete the certificate requirements and would hopefully help with the internal motivation for participants to engage with the educational opportunity.

In an ideal world, any virtual education program would culminate in a period of practical training and assessment, best achieved by having an expert from the provider organization conduct onsite consolidation training and competence evaluation. While ideal, this can be extremely cost prohibitive so other strategies need to be sought for these activities.

Conclusions

It is clear that building the skills of professional staff to safely operate the growing number of linear accelerators in Ethiopia must be a priority. In the face of many challenges including funding and time, it is perceived that virtual collaborative twinning partnerships for educational programs could be a key to supporting the country with this initiative. The effectiveness of these interventions must be maximized through reflection and continual analysis of what does and doesn’t work, and continuous efforts made to address challenges and make improvements.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.