Simulation-Based Education of Health Workers in Low- and Middle-Income Countries: A Systematic Review

Simulation-based education (SBE) is increasingly used to improve clinician competency and patient care and has been identified as a priority by the World Health Organization for low- and middle-income countries (LMICs). The primary aim of this review was to investigate the global distribution and effectiveness of SBE for health workers in LMICs. The secondary aim was to determine the learning focus, simulation modalities, and additional evaluation conducted in included studies. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta Analysis guidelines, searching Ovid (Medline, Embase, and Emcare) and the Cochrane Library from January 1, 2002, to March 14, 2022. Primary research studies reporting evaluation at Level 4 of The Kirkpatrick model were included. Studies on simulation-based assessment and validation were excluded. Quality and risk-of-bias assessments were conducted using appropriate tools. Narrative synthesis and descriptive statistics were used to present the results. A total of 97 studies were included. Of these, 54 were in sub-Saharan Africa (56%). Forty-seven studies focused on neonatology (48%), 29 on obstetrics (30%), and 16 on acute care (16%). Forty-nine used mannequins (51%), 46 used scenario-based simulation (47%), and 21 used synthetic part-task trainers (22%), with some studies using more than 1 modality. Sixty studies focused on educational programs (62%), while 37 used SBE as an adjunct to broader interventions and quality improvement initiatives (38%). Most studies that assessed for statistical significance demonstrated at least partial improvement in Level 4 outcomes (75%, n=81). SBE has been widely applied to improve outcomes in a variety of contexts across LMICs. Modalities of simulation are typically low-technology versions. However, there is a lack of standardized reporting of educational activities, particularly relating to essential features of SBE. Further research is required to determine which approaches are effective in specific contexts.