Oncology training and education initiatives in low and middle income countries: a scoping review

Background The global cancer burden falls disproportionately on low and middle-income countries (LMICs). One significant barrier to adequate cancer control in these countries is the lack of an adequately trained oncology workforce. Oncology education and training initiatives are a critical component of building the workforce. We performed a scoping review of published training and education initiatives for health professionals in LMICs to understand the strategies used to train the global oncology workforce. Methods We searched Ovid MEDLINE and Embase from database inception (1947) to 4 March 2020. Articles were eligible if they described an oncology medical education initiative (with a clear intervention and outcome) within an LMIC. Articles were classified based on the target population, the level of medical education, degree of collaboration with another institution and if there was an e-learning component to the intervention. Findings Of the 806 articles screened, 25 met criteria and were eligible for analysis. The majority of initiatives were targeted towards physicians and focused on continuing medical education. Almost all the initiatives were done in partnership with a collaborating organisation from a high-income country. Only one article described the impact of the initiative on patient outcomes. Less than half of the initiatives involved e-learning. Conclusions There is a paucity of oncology training and education initiatives in LMICs published in English. Initiatives for non-physicians, efforts to foster collaboration within and between LMICs, knowledge sharing initiatives and studies that measure the impact of these initiatives on developing an effective workforce are highly recommended.


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In 2018, it was estimated that 18.1 million new cancer cases and 9.6 million cancer deaths occurred worldwide [1]. By 2040, the World Health Organization (WHO) estimates that global cancer cases will reach 29.5 million and there will be 16.5 million cancer related deaths [2]. Although high income countries (HICs) have higher cancer incidence rates, cancer mortality rates are significantly higher in low and middleincome countries (LMICs) (defined by the World Bank as countries with a gross national income of $12,535 or less in 2019 [3]) and continue to rise [4]. The proportion of cancer deaths in LMICs is expected to increase to 75% by 2030 [2,5].
One of the major barriers to cancer control in LMICs is training an adequate oncology workforce [6]. On average, LMICs have 1.3 physicians and 2.5 nurses per 1,000 people compared with 3.1 physicians and 10.9 nurses per 1,000 people in HICs [7,8]. As a result, case volumes and clinical workload are significantly higher for oncology providers in LMICs compared with HICs [9]. There are significant shortages in the oncology workforce, including specialists with skills in pathology, radiation and medical oncology [6]. Furthermore, the absence of sufficient oncology training programmes and lack of focus on cancer care during medical school provide significant challenges towards training and retaining cancer care professionals [10]. Given the rising cancer burden and limited workforce, it is essential to develop, promote and support local oncology education and training initiatives in LMICs.
Some traditional approaches to building the oncology workforce in LMICs such as travelling to HICs to acquire necessary skills may have unintended harmful consequences to LMIC health care systems [10]. The 'brain drain', when trainees do not return to their native country to practice medicine, has been recognised by the WHO as a major problem that propagates imbalances in the global health workforce [11]. To combat this, several global oncology initiatives have focused on building local capacity to provide high-quality cancer care [10]. One such mechanism involves building partnerships between institutions facilitating bi-directional learning and knowledge transfer, and enabling local retention and capacity building [10]. Furthermore, e-learning is increasingly being used to supplement learning in LMICs. Given the absence of a systematic examination of oncology education and training initiatives in LMICs, this scoping review was performed.

Methods
Scoping reviews facilitate the examination of a broad topic of interest with the purpose of identifying gaps in the evidence, clarifying concepts and synthesising what is known about a topic [12]. We selected a scoping review methodology due to the paucity of empirical literature on this subject as well as to provide an overview of available information regarding oncology education and training in LMICs. This review aims to provide a description of the depth and breadth of the educational initiatives within this field [13]. We applied a rigorous approach to this scoping review through a five-step approach to ensure reliability: (1) identify the research question, (2) identify relevant studies, (3) select studies, (4) chart the data and (5) collate, summarise and report the results [13,14].

Identify the research question
Our scoping review was centred on the following research question: What has been published on oncology education and training to healthcare professionals in LMICs between the years 1947 and 2020?

Identify relevant studies
A qualified medical librarian assisted in the development and execution of the search strategy in two major electronic databases: Ovid MED-LINE and Embase up to 4 March 2020 (date of the search). We felt that these two databases would capture the majority of the published literature in this field and that including additional databases would not yield a significant increase in the number of results. The search string is shown in Supplementary Appendix A. The reference lists of relevant review papers and articles found during the search of the databases were also scanned for additional eligible articles.

Select studies
A two-stage standardised screening process was used to evaluate the eligibility of the articles identified in the search using Covidence systematic review software (Covidence Systematic Review Software 2019). Two independent reviewers (MJ and SM) screened the title and abstracts of the captured articles using the pre-defined eligibility criteria. The same reviewers screened the full-text articles that passed stage 1 review. If there was uncertainty as to whether an article should be included, a third author was asked to provide input (SK).
We applied pre-determined eligibility criteria to the selection process. Eligible articles described a specific oncology medical education initiative targeted towards individuals residing in a LMIC. The initiative must have described one or more specific interventions as well as an outcome of that intervention. Oncology education was broadly defined to include any teaching within the following disciplines: surgical oncology, medical oncology, radiation oncology, haematologic oncology, gynaecological oncology and/or topics: research skills, pathology, diagnosis, treatment, supportive care or palliative care. We excluded any article that did not meet the above criteria as well as review articles, letters, commentaries, book chapters, abstracts and unpublished manuscripts.

Chart the data
Data were extracted using a pre-developed data extraction tool which included the terms: author, year, geographical area, host county(ies), host site/institution, collaborations, partner country, partner institution, location of training, project title, target population, level of education, use of e-learning, oncology discipline, programme duration (i.e. short (up to 1 month), medium (>1 month to 1 year), long-term (>1 year)), educational outcome(s) and funding. For the purposes of this study, e-learning was defined as learning facilitated by electronic technologies and involving access to a curricula outside of a traditional classroom, often in the form of interactive multimedia, audiovisual clips and virtual models [15].

Collate, summarise and report the results
A descriptive numerical summary of the characteristics of the studies was performed. Tables were created to show the overall number of studies included, the target study population, level of medical education, publication year, use of e-learning, oncology discipline, programme duration, educational outcome(s) and funding. As per scoping review methodology, an assessment of the quality of the included studies was not performed [15].
We also classified the impact of the studies' based on the 4-level model by Kirkpatrick that measures the outcomes of a particular education study or training programme [16]. These levels include: (1) reaction, (2) learning, (3) behaviour and (4) results.

Target population and location
Fifteen of the twenty-five articles described an education initiative for physicians [17, 20, 23-25, 27, 29, 30, 33, 35-40]. Four articles described an initiative for nurses [19,21,28,31], and one article was aimed at pharmacists [26]. Five articles described initiatives for more than one member of the health care team: three initiatives were for physicians and nurses [18,22,32], one was for physicians, nurses and pharmacists [41] and one was for physicians, nurses and other non-health professionals [34].

Level, topic and duration of education initiative
Continuing medical education (CME) initiatives (8 of 15) were the most common level of medical education for physicians, followed by graduate medical education (GME) initiatives (3 of 15), and a combination of CME/GME initiatives (2 of 15). There were only two initiatives for medical students (undergraduate medical education (UME)) [23,33]. All four initiatives targeting nurses [19,21,28,31] and the one initiative for pharmacists [26] were CME.

Use of e-learning
Eleven articles described a component of e-learning in their educational intervention. Six studies included the use of telehealth technology [18,22,24,26,35,37], one used smartphone-based training [19], two used online teaching modules [17,39] and one used simulations [28].

Collaborations
Almost all (24 of 25) educational initiatives were implemented with a collaborating organisation. The collaborating organisations were most often located in HICs, including fourteen from the United States [17, 19-22, 24-27, 29-32, 40], three from Canada [18,35,39], one from both the United States and Canada [28], two from the United Kingdom [38,41] and one from Hong Kong [36]. Two articles described collaborations with a variety of international agencies, including the WHO [33,34], and the International Agency for Research on Cancer (IARC) [34]. The article by Agrawal et al [37] was the only study to describe an in-country collaboration between two different institutions in India. Twelve articles noted that the collaboration between institutions was highly rewarding and beneficial in fostering bi-directional learning [18, 20, 21, 24, 30, 32, 34-36, 38, 40, 41].
The majority of the educational initiatives took place solely within the host LMIC (i.e. in-country training). Five initiatives had both in-country and out-of-country components to their training programmes, which involved travel to the collaborating organisation [24,27,29,36,41]. Only one initiative described an intervention that was solely located out-of-country, where participants spent the entire 3-6 weeks training at the collaborating organisation [40].

Capacity building
Seven studies focused on building local capacity through their medical education initiative. Five initiatives implemented a 'train the trainer' model where learners who had completed the educational intervention previously would then serve as the instructor ('trainer') for the next cohort of learners [27,28,34,36,38]. This was done to build capacity and self-sustainability within the LMIC. Barron et al [21] described the future of their educational programme to include a focus on preceptorship development so that nurses would become skilled teachers thereby helping to ensure that the training programme becomes self-sustaining. Fish et al [40] describe the potential to build local capacity as a result of their educational intervention by laying the foundation for continued international research collaborations and connections.

Impact of educational initiative
Based on the Kirkpatrick programme evaluation training model's 4-levels of impact, 10 articles exclusively measured reaction outcomes [18,22,23,26,27,29,32,33,36,37]. These were assessed primarily though surveys using Likert-scale, multiple choice and/or open-ended questions. Seven articles exclusively measured learning outcomes [17,19,20,25,30,31,34], most commonly through pre/post written tests. Two articles exclusively measured behaviour outcomes [35,41]. For example, Lewis and Tibenderana [41] showed that after a series of training sessions in the safe handling, preparation and administration of chemotherapy, there was an increase in the rate of documented chemotherapy prescriptions which were correctly administered to patients compared to the pre-training levels. Three articles reported both reaction and learning outcomes [28,38,40], two articles learning and behaviour outcomes [24,39] and one article reported learning and results outcomes [21]. The result outcome in this article pertained to the success of a bone marrow transplant programme in Bangladesh in the months following training of nurses.

Challenges
Several challenges were identified in implementing the educational initiative. Language barriers [17,27,34] and the lack of protected time for the learners to participate in the initiative were often identified [27,28,31]. Four articles also noted encountering technical problems [19,22,26,37] (i.e. Internet connectivity, videoconferencing equipment dysfunction) and four articles described infrastructure limitations (i.e. limited medical supplies, lack of accurate medical records) within the LMIC [19,20,22,38]. The logistics and expenses of international travel was identified as a challenge in three articles [27,29,40]. Cultural differences and political/workforce changes were also highlighted in one article [38]. Eleven articles did not disclose their challenges in the implementation of the initiative [20-24, 28, 29, 31, 38, 40, 41].

Funding
The majority of the initiatives were partially or fully funded by external grants and/or by a charitable foundation located in the partner country [17,18,22,24,27,31,34,36]. One initiative was partially funded by the collaborating country's institution [19] and one initiative was partially funded by the collaborating country's government [41] while another was funded by a grant through the host country's government [37]. Other sources of funding included research institutes [22,23], a pharmaceutical company [22] (partial funding) and a fellowship award [32]. Ten articles did not disclose the source of funding for their initiative [20,21,25,26,28,30,33,35,38,39].

Discussion
Medical education and training initiatives in oncology are a critical element in developing an effective workforce to manage rising cancer incidence and mortality rates in LMICs. In this scoping review, we identified 25 articles that described an oncology medical education initiative. The majority of these initiatives were aimed at physicians and CME. Almost all the initiatives were in partnership with a collaborating organisation from a HIC. In addition, based on Kirkpatrick's 4-level model, the majority of initiatives evaluated only reaction outcomes. Finally, less than half of the initiatives involved a component of e-learning.
With only 25 articles identified, there is a clear paucity of published literature on educational initiatives in the field of oncology. This may be due to an absence of studies investigating this topic, or these initiatives are not being widely published in the peer-reviewed medical literature. For example, in LMICs, the emphasis may be on implementing an educational programme, and due to time, financial and/or language constraints, publication of such work, at least in full-text format, may not be possible. Over time, we found a gradual increase in the number of published manuscripts, with only six articles published before 2010 compared to 19 between 2010 and 2020 ( Figure 3). This increase is encouraging as publication allows others to learn important lessons for design and implementation of medical education initiatives in oncology in LMICs. Where possible, efforts to assist educators in overcoming obstacles to conducting and publishing studies related to their initiatives could be considered. On the other hand, less onerous methods of disseminating important findings should also be encouraged.
The majority of the initiatives included in our scoping review were aimed towards physicians in LMICs. While the training of physicians is important, well-trained and skilled allied health professionals, including nurses and pharmacists, are also critical for the effective delivery of cancer care [42]. Education and training of other non-physician providers is integral to the workforce crisis in LMICs, and is necessary in order to build a strong cancer-care delivery infrastructure. Furthermore, inter-professional education and collaboration has been proposed by the WHO as a promising solution to ensure the appropriate supply, mix and distribution of the global health workforce [43]. Only five studies in our scoping review targeted multiple members of the healthcare team [18,22,32,34,41], showing that further focus on inter-professional education initiatives is warranted.
Our study also found that the majority of initiatives were focused on CME. This type of medical education is important for practicing health care providers to maintain competence and learn about new and developing areas within their field. However, if foundational education in oncology is not being provided in the earlier stages of health professions education, individuals may not have adequate exposure to the field in order to choose it as a speciality or profession. The lack of focus on oncology in medical school curricula in LMICs may have been due to an increased focus on infectious diseases, which historically has been the major concern in these countries [6]. However, with the growing burden of cancer in LMICs, it is also important to include cancer as a core discipline in undergraduate health professions education.
Over the past few decades, there has been increased interest from institutions from HICs to form partnerships with those from LMICs [46]. However, there is cause for concern that in many cases these partnerships may be driven by the funding and interests of the HIC partner, and that the needs of the LMIC institution are not fully considered [44]. Other concerns with these 'North-South' partnerships have also been raised, including the low degree of sustainability and a focus on short-term goals instead in long-term capacity building [45]. While several of the initiatives identified in our review had long-term partnerships and there was a focus on capacity building, almost all of these partnerships were with organisations from HICs. In recent years, 'South-South' collaborations (i.e. from within the same LMIC or between different LMICs) have gained popularity in the delivery of health professionals education due to several advantages, including better alignment with local needs, ability to engage senior leaders within the institutions and ensuring long-term sustainability [46]. The vast majority of the studies in our scoping review used either reaction or learning outcomes as their method of evaluation. These represent the two lowest levels of impact in Kirkpatrick's framework [16]. These evaluation methods are the most easily measured and implemented, but also are the least effective over time. Conversely, behaviour and result outcomes are more difficult to implement, take longer to measure and are often more costly. However, the goal of any medical educational initiative should be to improve patient outcomes, which are evaluated in level four of the Kirkpatrick model. As oncology medical education initiatives become more prevalent, and as collaborations develop into longer-term relationships, it will be important that all four levels of Kirkpatrick's model are evaluated to improve the impact of these initiatives.
LMICs require effective and affordable medical education strategies to address the limited and poorly trained workforce. In a recent systematic review of e-learning for medical education in LMICs from 2007 to 2017, Barteit et al [47] included 52 articles and concluded that e-learning in LMICs has not met its expected potential. They proposed that some reasons for the limited success of e-learning implementation may be due to financial resources and that educational organisations may not be giving e-learning a strong mandate as an educational method. Our findings, where only 11 of the 25 studies used a component of e-learning as part of their educational initiative, support the conclusion that e-learning may still be underutilised as an educational method in LMICs. Similarly, in a scoping review of e-learning for primary healthcare, Reeves et al [48] found that of 23 studies published on this topic, only two were from LMICs. E-learning initiatives have the potential to offer highly effective, low-cost and high-quality education, especially in resource limited settings but will likely require a combined effort and commitment from a variety of national and international stakeholders in order to meet its full potential [47].
Our study should be interpreted in the context of certain limitations. First, we employed a scoping review methodology that does not assess the rigour or quality of the included studies. Second, we chose to include only two databases (Ovid MEDLINE and Embase) and excluded programmes in the gray literature (i.e. abstracts), where many educational initiatives may have been highlighted. Finally, despite efforts to optimise the search terms in this scoping review, we may have missed certain medical education initiatives that were indexed under different terms.

Conclusion
In conclusion, oncology training and education initiatives for health care professionals in LMICs are an essential component in building the workforce to address the growing cancer burden and to ensure that the workforce is well-trained to provide excellent care to cancer patients. This scoping review identifies a broad range of initiatives that have been published and the strategies used to implement them. In the coming years, we recommend that educators share valuable lessons learned related to the creation and execution of their programmes, including, where possible, performing and publishing studies of their work in order to optimise educational strategies. This may be achieved by establishing an online registry of oncology educational initiatives occurring across various LMICs and/or organising regional/national focused meetings that aim to share knowledge on best practices for delivering educational programmes. Furthermore, the design and delivery of oncology education for non-physician health professionals and between various health professionals should be prioritised to ensure optimal collaboration and teamwork within the global oncology workforce. Finally, in addition to long-term partnerships with HIC organisations, we encourage organisations within LMICs to foster collaborative relationships within their country or from other LMICs to better address local needs, contexts and ensure long-term sustainability of their educational initiatives.

Funding
This manuscript was supported by the University of Calgary Global Oncology Programme.