Effectiveness of Low-cost, Technology-enhanced Simulation Training for Healthcare Training in Low-and Middle-income Countries (LMICs): A Systematic Literature Review.

Abstract

Background: Simulation-based training is essential for enhancing healthcare education and patient safety. However, its implementation often requires significant financial investment, limiting access in low- and middle-income countries (LMICs). Adapting simulation techniques to low-cost alternatives could improve accessibility and reduce educational disparities across global settings. This review aims to synthesize evidence on low-cost, technology-enhanced educational tools for healthcare training in resource-constrained settings.

Methods: We searched Medline (PubMed), CINAHL, Cochrane CENTRAL, Web of Science, Scopus, and Embase until August 31, 2024. Eligible studies involved LMICs, health trainees, and low-cost, technology-enhanced simulation tools for resource-constrained settings. We excluded comments, reviews, editorials, and studies not meeting these criteria. The review followed PRISMA guidelines, and study quality was assessed via the Downs and Black scale. This study was registered on PROSPERO (CRD42024554815) and received no funding.

Results: A total of 13 studies were included: six randomized trials and seven nonrandomized trials. These studies assessed various learning tools, including smartphone apps (six), virtual or augmented reality (three), telesimulation (two), a virtual simulation website (one), and a high-fidelity simulator (one), across multiple healthcare disciplines. Most studies have reported positive learning outcomes, such as improved skills and knowledge, although none have assessed long-term behavioral changes or patient outcomes. The reported barriers included internet connectivity issues, software instability, language limitations, and variability in prior knowledge. User satisfaction was generally high.

Discussion: This review highlights scalable, technological simulation tools for LMICs that improve medical training in resource-limited settings. It adheres to PRISMA guidelines, ensuring rigor, and includes studies from multiple continents and healthcare disciplines. Limitations include variations in low-cost tool definitions, study quality, and a lack of long-term behavior or clinical impact assessment. Additionally, comparisons often involve traditional learning methods rather than high-fidelity simulation tools used in high-income countries, and no cost-effectiveness analyses have been conducted.