This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Figure 2).
Figure 2: Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram
Initial database searches returned 116 articles of which 10 were duplicates. Eighty-eight 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 19 papers being exported for review. All 19 papers have been included in the final data extraction, analysis, and reporting process (Table 1).(22–40)
Table 1: Summary of 19 studies included in the scoping review
Across 17 studies evaluating published research on SBL in undergraduate surgical education, the median Medical Education Research Study Quality Instrument score was 11.25 (range 5.5 – 15.5, out of possible 18).
Studies that met the inclusion criteria were conducted across a range of 10 countries in SSA. Based on African Union regions, East Africa hosted 77.8% (n=14) of the referenced programs in contrast to Central Africa, which had no documented undergraduate surgical SBL programs (Figure 3). West and Southern Africa hosted only 11.1% (n=2) 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 (78.9%, n=15) were only recently introduced (from 2017 through 2021).
Figure 3: Geographical Distribution of Studies on Undergraduate Surgical Simulation-based Learning in Sub-Saharan Africa
Programs targeted various undergraduate learners, including medical students (63.2%, n=12), nursing students (21.1%, n=4), dental students (5.2%, n=1), pre-interns (10.5%, n=2), emergency medical care students (5.2%, n=1), and undergraduate anaesthesia students (5.2%, n=1). Up to one-fifth (n=4) of the simulation use could be considered multi-disciplinary, including both medical, nursing and/or dental school students within the same program. Most surgical SBL was targeted at senior clinical students - only one in four programs documented its use within the first half of undergraduate training. Up to 57.1% (n=8/14) of the documented simulation programs were newly introduced at the time they were being studied. Only 36.8% (n=7) were planned as sustained, recurring programs.
Over half (57.9%, n=11) of the included programs explicitly utilized low-fidelity models. 26.3% (n=5) utilized high-fidelity models only for training, and a minority (15.8%, n=3) utilized a combination of both high- and low-fidelity modalities within the same program. 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 (57.9%, n=11). The most commonly taught technical skills were acute resuscitation including cardiopulmonary resuscitation (31.6%, n=6), airway management (26.3%, n=5), suturing of lacerations (26.3%, n=5), surgical knot tying (21.1%, n=4), chest tube insertion (21.1%, n=4) and orthopaedic casting (21.1%, n=4) (Table 2). Whilst all programs included at least some aspect of surgical technical skills training, 15.8% also formally addressed non-technical skills, including teamwork, inter-professional communication skills, decision making, and time management.
Next, we mapped the surgical skills taught via simulation onto the list of essential surgical procedure for the Primary Health Centre (PHC) and First-Level (i.e. district general/rural) Hospital, as defined by World Bank Disease Control Priority Program (DCP3) (Table 3).(16) 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 three of the nineteen programs (15.8%) had specific collaborations between engineers and physicians for the conception, design, or execution of SBL.
Table 2: Topics covered in SSA simulation programs
Table 3: Overlap between essential surgical procedures and simulation-based learning for undergraduate learners in Sub-Saharan Africa