Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review

Background:
Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment.

Objective:
We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs).

Methods:
We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD).

Results:
A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs.

Conclusions:
The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.

The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants

Background
Musculoskeletal (MSK) conditions, MSK pain and MSK injury/trauma are the largest contributors to the global burden of disability, yet global guidance to arrest the rising disability burden is lacking. We aimed to explore contemporary context, challenges and opportunities at a global level and relevant to health systems strengthening for MSK health, as identified by international key informants (KIs) to inform a global MSK health strategic response.

Methods
An in-depth qualitative study was undertaken with international KIs, purposively sampled across high-income and low and middle-income countries (LMICs). KIs identified as representatives of peak global and international organisations (clinical/professional, advocacy, national government and the World Health Organization), thought leaders, and people with lived experience in advocacy roles. Verbatim transcripts of individual semi-structured interviews were analysed inductively using a grounded theory method. Data were organised into categories describing 1) contemporary context; 2) goals; 3) guiding principles; 4) accelerators for action; and 5) strategic priority areas (pillars), to build a data-driven logic model. Here, we report on categories 1–4 of the logic model.

Results
Thirty-one KIs from 20 countries (40% LMICs) affiliated with 25 organisations participated. Six themes described contemporary context (category 1): 1) MSK health is afforded relatively lower priority status compared with other health conditions and is poorly legitimised; 2) improving MSK health is more than just healthcare; 3) global guidance for country-level system strengthening is needed; 4) impact of COVID-19 on MSK health; 5) multiple inequities associated with MSK health; and 6) complexity in health service delivery for MSK health. Five guiding principles (category 3) focussed on adaptability; inclusiveness through co-design; prevention and reducing disability; a lifecourse approach; and equity and value-based care. Goals (category 2) and seven accelerators for action (category 4) were also derived.

Conclusion
KIs strongly supported the creation of an adaptable global strategy to catalyse and steward country-level health systems strengthening responses for MSK health. The data-driven logic model provides a blueprint for global agencies and countries to initiate appropriate whole-of-health system reforms to improve population-level prevention and management of MSK health. Contextual considerations about MSK health and accelerators for action should be considered in reform activities.

A Qualitative Analysis of Burn Injury Patient and Caregiver Experiences in Kwazulu-Natal, South Africa: Enduring the Transition to a Post-Burn Life

Over 95% of fire-related burns occur in low- and middle-income countries (LMICs), an important and frequently overlooked global health disparity, yet research is limited from LMICs on how survivors and their caregivers recover and successfully return to their pre-burn lives. This study examines the lived experiences of burn patients and caregivers, the most challenging aspects of their recoveries, and factors that have assisted in recovery. This qualitative study was conducted in KwaZulu-Natal, South Africa at a 900-bed district hospital. Participants (n = 35) included burn patients (n = 13) and caregivers (n = 22) after discharge. In-depth interviews addressed the recovery process after a burn injury. Data were coded using NVivo 12. Analysis revealed three major thematic categories. Coded data were triangulated to analyze caregiver and patient perspectives jointly. The participants’ lived experiences fell into three main categories: (1) psychological impacts of the burn, (2) enduring the transition into daily life, and (3) reflections on difficulties survivors face in returning for aftercare. The most notable discussions regarded stigma, difficulty accepting self-image, loss of relationships, returning to work, and barriers in receiving long-term aftercare at the hospital outpatient clinic. Patients and caregivers face significant adversities integrating into society. This study highlights areas in which burn survivors may benefit from assistance to inform future interventions and international health policy.

Barriers and enablers to country adoption of National Surgical, Obstetric, and Anesthesia Plans

This paper examines the adoption and diffusion of National Surgical Obstetric and Anaesthesia Plans (NSOAPs), a policy instrument, to improve surgical healthcare services in low- and middle-income countries (LMICs). It draws on recent trends in health system reform and empiricism to understand NSOAP effectiveness for large-scale improvement in surgical system objectives (surgical outcomes, patient satisfaction and financial risk protection). While the study reveals that NSOAP adoption has occurred in several countries, its translation into effective, responsive and equitable coverage of surgical healthcare services (diffusion) with enduring impact has yet to occur on a large-scale. NSOAP adoption and diffusion has been constrained by two principal considerations: (I) suboptimal funding allocation to develop NSOAPs and implement within a health system context; (II) inadequate translation of the NSOAP into implementable activities that lead to improved health system performance. We argue that a systems perspective—dynamically optimizing the NSOAP in relation to specific health system, adoption system, and contextual factors—may enhance the scale-up of NSOAPs and lead to sustainably funded programs that enhance the effectiveness, efficiency, responsiveness and equity of surgical healthcare service over the long-term. We explore three specific areas—technology, financing, governance—which could be harnessed to enhance the adoption and diffusion of NSOAPs.

Analysing a Global Health Education Framework for Public Health Education Programs in India

Academic global health is of increasing interest to educators and students in public health but competency domains as well as education pathways that deliver this training, are still being identified and refined. This thesis was undertaken using an education program development paradigm and aimed to analyse the factors shaping global health education in India by examining multistakeholder perspectives. The research framework consisted of four components: curriculum and content, students, faculty and key experts, and employers. Studies captured the perspectives of students through a survey and focus group discussions, faculty and other key experts through semi-structured interviews, and employers through job advertisement analysis. We identified eleven global health competency domains focussed on three aspects: foundational competencies, core public health skills and soft skills. Global health and public health were seen as interconnected, with global health having transnational context and public health having a more national focus. Global health was seen as a nascent concept in India and although integration of global health education into the public health curriculum was supported, there were concerns given that public health is still too new a discipline in India. Global health competencies were seen as a ‘step up’ from the public health competencies. Based on the results, a two-level approach to global health education is proposed for Indian public health institutions. The first approach, targeted at recent graduates, focuses on a ‘foundational global health education’ within public health programs such as an MPH. The second approach is an ‘Executive Global Health Certificate Program’, aimed at experienced public health professionals planning to enter the global health workforce. This thesis has outlined a framework for Indian and other LMIC institutions looking to expand the scope of public health education and intend to develop global health education programs.

The Role of Noncommunicable Diseases in the Pursuit of Global Health Security

Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.

Medical Students in Global Neurosurgery: Rationale and Role

Global neurosurgery aims to build equity in neurosurgical care worldwide. The active involvement of early-career general practitioners, neurosurgical residents, and medical students in global neurosurgery is critical for the development of sustainable strategies to address inequalities. However, the rationale for medical student involvement in global neurosurgery and strategies to increase medical student involvement have not been described previously. We characterize why medical students are fundamental to the success of global neurosurgery initiatives, outline existing opportunities for medical students in the global neurosurgery space, and delineatehow to incorporate medical students into various global neurosurgery initiatives

New Frontiers for Fairer Breast Cancer Care in a Globalized World

In early 2020, the book “Breast cancer: Global Quality Care” was published by Oxford University Press. In the year since then, publications, interviews (by ecancer), presentations, webinars, and virtual congress have been organized to disseminate further the main message of the project: “A call for Fairer Breast Cancer Care for all Women in a Globalized World.” Special attention is paid to increasing the “value-based healthcare” putting the patient in the center of the care pathway and sharing information on high-quality integrated breast cancer care. Specific recommendations are made considering the local resource facilities. The multidisciplinary breast conference is considered “the jewel in the crown” of the integrated practice unit, connecting multiple specializations and functions concerned with patients with breast cancer. Management and coordination of medical expertise, facilities, and their interfaces are highly recommended. The participation of two world-leading cancer research programs, the CONCORD program and Breast Health Global Initiative, in this project has been particularly important. The project is continuously under review with feedback from the faculty. The future plan is to arrive at an openaccess publication that is freely available to all interested people. This project is designed to help ease the burden and suffering of women with breast cancer
across the glob

Assessment of Laparoscopic Instrument Reprocessing in Rural India: A Mixed Methods Study

Background
Laparoscopy is a minimally-invasive surgical procedure that uses long slender instruments that require much smaller incisions than conventional surgery. This leads to faster recovery times, fewer infections and shorter hospital stays. For these reasons, laparoscopy could be particularly advantageous to patients in low to middle income countries (LMICs). Unfortunately, sterile processing departments in LMIC hospitals are faced with limited access to equipment and trained staff and poses an obstacle to safe surgical care. The reprocessing of laparoscopic devices requires specialised equipment and training. Therefore, when LMIC hospitals invest in laparoscopy, an update of the standard operating procedure in sterile processing is required. Currently, it is unclear whether LMIC hospitals, that already perform laparoscopy, have managed to introduce updated reprocessing methods that minimally invasive equipment requires. The aim of this study was to identify the laparoscopic sterile reprocessing procedures in rural India and to test the effectiveness of the sterilisation equipment.
Methods
We assessed laparoscopic instrument sterilisation capacity in four rural hospitals in different states in India using a mixed-methods approach. As the main form of data collection, we developed a standardised observational checklist based on reprocessing guidelines from several sources. Steam autoclave performance was measured by monitoring the autoclave cycles in two hospitals. Finally, the findings from the checklist data were supported by an interview survey with surgeons and nurses.
Results
The checklist data revealed the reprocessing methods the hospitals used in the reprocessing of laparoscopic instruments. It showed that the standard operating procedures had not been updated since the introduction of laparoscopy and the same reprocessing methods for regular surgical instruments were still applied. The interviews conrmed that staff had not received additional training and that they were unaware of the hazardous effects of reprocessing detergents and disinfectants.
Conclusion
As laparoscopy is becoming more prevalent in LMICs, updated policy is needed to incorporate minimally invasive instrument reprocessing in medical practitioner and staff training programs. While reprocessing standards improve, it is essential to develop instruments and reprocessing equipment that is
more suitable for resource-constrained rural surgical environments.

Surgical and Trauma Capacity Assessment in Rural Haryana, India

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified.

Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools.

Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively.

Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures.

Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.