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Review

Advancing Medical Education Using Virtual and Augmented Reality in Low- and Middle-Income Countries: A Systematic and Critical Review

by
Xi Li
1,
Dalia Elnagar
2,
Ge Song
1 and
Rami Ghannam
1,*
1
James Watt School of Engineering, University of Glasgow, Glasgow G12 8QQ, UK
2
Department of Computer Science and Engineering, The American University in Cairo, New Cairo 11835, Egypt
*
Author to whom correspondence should be addressed.
Virtual Worlds 2024, 3(3), 384-403; https://doi.org/10.3390/virtualworlds3030021
Submission received: 12 June 2024 / Revised: 19 August 2024 / Accepted: 26 August 2024 / Published: 18 September 2024
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Abstract

:
This review critically examines the integration of Virtual Reality (VR) and Augmented Reality (AR) in medical training across Low- and Middle-Income Countries (LMICs), offering a novel perspective by combining quantitative analysis with qualitative insights from medical students in Egypt and Ghana. Through a systematic review process, 17 peer-reviewed studies published between 2010 and 2023 were analysed. Altogether, these studies involved a total of 887 participants. The analysis reveals a growing interest in VR and AR applications for medical training in LMICs with a peak in published articles in 2023, indicating an expanding research landscape. A unique contribution of this review is the integration of feedback from 35 medical students assessed through questionnaires, which demonstrates the perceived effectiveness of immersive technologies over traditional 2D illustrations in understanding complex medical concepts. Key findings highlight that VR and AR technologies in medical training within LMICs predominantly focus on surgical skills. The majority of studies focus on enhancing surgical training, particularly general surgery. This emphasis reflects the technology’s strong alignment with the needs of LMICs, where surgical skills training is often a priority. Despite the promising applications and expanding interest in VR and AR, significant challenges such as accessibility and device limitations remain, demonstrating the need for ongoing research and integration with traditional methods to fully leverage these technologies for effective medical education. Therefore, this review provides a comprehensive analysis of existing VR and AR applications, their evaluation methodologies, and student perspectives to address educational challenges and enhance healthcare outcomes in LMICs.

1. Introduction

Today, the world of medicine is facing many challenges, ranging from the shortages of health workers in Low- and Middle-Income Countries (LMICs) to the urgent need for specialised training [1]. To solve these problems, new tools like Virtual Reality (VR) and Augmented Reality (AR) are emerging as pivotal tools, particularly since VR can be used for anything DICE (Dangerous, Impossible, Counterproductive or Expensive) [2].
Historically, medical education has been a blend of theoretical knowledge and practical exposure. Cadavers, for instance, have been the cornerstone of anatomy teaching for centuries. However, not only are they expensive and ethically challenging but their availability is also limited [3,4]. Therefore, traditional medical teaching methods, although time-tested, present financial, ethical, and logistical challenges that, in today’s fast-paced and ever-evolving medical landscape, often prove limiting. However, with VR and AR, medical students can practise in a computer-generated environment, which means they can try things many times without any real-world risks [5].
The essence of medical training is rooted in practice [6]. It is about making decisions in real time, handling stress, and repeatedly engaging in complex procedures until they become second nature. In comparison to traditional clinical education, deliberate practice in simulation-based medical education has been proven to offer more significant benefits [7,8]. This repetitive and immersive practice is where VR, with its highly realistic simulations, demonstrates significant potential. Learners have the opportunity to engage in realistic scenarios without the fear of adverse effects on actual patients [9].
Moreover, medicine is an inherently collaborative discipline [10]. Whether it is nurses and doctors working in teams during operations or different departments discussing complicated cases, no medical professional works in isolation. VR can help train the team members to maintain good collaboration and communication skills in emergency situations [11,12]. For example, a student in Egypt may be able to practise a procedure with a student in India while both are being guided by an experienced professor from the UK—all of them brought together in a virtual environment. This demonstrates the transformative potential of VR technology in enhancing teamwork and collaboration without the constraints and costs of traditional travel or logistics [13,14]. In fact, removing such geographic boundaries promises new co-learning opportunities as well as the integration of diverse cultural insights and clinical experiences for learners.
Another benefit of VR is that it can offer the same training experience to everyone, everywhere. With VR, every scenario can be controlled, replicated, and assessed uniformly, ensuring that learners receive standardised and consistent quality education [15,16]. Furthermore, integrating Artificial Intelligence (AI) into these virtual platforms can provide in-depth performance analytics, tailor scenarios to individual learner needs, and make virtual patient [17,18] interactions more realistic. Combining the concepts of standardised medical education and virtual patients is called virtual standardised patients (VSPs), which can make learning more personal and realistic without losing consistency and credibility [19]. This dynamic synergy of VR and AI can make learning more personal and realistic.
In an effort to achieve the Sustainable Development Goals (SDGs) by 2030, particularly goal 3C, which stresses the enhancement of the health workforce in income-limited countries, digital technologies such as VR can help achieve this [20]. With their versatility, they can mirror varied training needs, ensuring that health professionals are equipped with a comprehensive skill set, from diagnostic skills to crucial communication abilities.
Some studies in LMICs have tried integrating extended reality (XR) technology into medical training, including the following fields: anatomy, surgery and human interpersonal behaviour (as shown in Figure 1). These applications seem to help increase the technical or non-technical skills of medical practitioners while further developing the medical career in LMICs. However, there are few medical applications of VR in LMICs. Also, the current research is still in the initial stage and lacks a systematic and critical literature review to elucidate the medical needs of LMICs.
This paper, therefore, seeks to comprehensively review the literature on the use of VR and AR in medical education and training in Low- and Middle-Income Countries, and to explore the real needs of LMICs through questionnaires. By examining their merits, understanding their limitations, and projecting their potential, we aim to provide a holistic overview of their role in shaping the future of medical education in these regions. To achieve these goals, several research questions should be addressed, as follows:
RQ1
What medical disciplines in training do immersive technology currently apply to?
RQ2
Is it necessary to use VR and AR in LMICs for medical education?
RQ3
What evaluation methods are used to measure the effectiveness of VR and AR for medical training in LMICs?
RQ4
Which medical disciplines in LMICs require immersive technology the most?
RQ5
What is the transformative potential of VR and AR to improve medical education?

2. Methodology

In this section, we demonstrate the research methodology used to explore the potential of Virtual Reality (VR) and Augmented Reality (AR) for medical training in Low- and Middle-Income Countries (LMICs). We use two complementary approaches: (A) A comprehensive systematic review and analysis of existing research to understand how VR and AR is used for medical training in LMIC settings. This will help answer RQ1–RQ4. (B) A focused survey is used, targeting medical students in Egypt and Ghana, which will gather data on their experiences and perspectives regarding VR and AR applications for medical training.

2.1. Literature Review

The literature review was based on the theory of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [27] and this study adhered to the guidelines outlined in the PRISMA-Checklist (see Supplementary Materials). The risks of bias were reduced by following a rigorous and transparent review protocol. The review protocol was not registered. It included four parts: (1) search strategy and selection criteria, (2) inclusion and exclusion criteria, (3) manual screening, and (4) review results.

2.1.1. Search Strategy and Selection Criteria

The reviews identified in this study were searched through the following main databases: IEEE Xplore Digital Library, University Digital Library, PubMed, ScienceDirect, and Scopus. The publications were only included from 1 January 2010, to 31 December 2023, as the increased use of VR and AR began in the early 2010s [28]. To ensure coverage of all relevant literature for this study, keywords used for search were classified into the four concepts of immersive technology, medical discipline, training methods, and resource-limited (shown in Table 1). The keywords were used alone or in combination. To accurately find the relevant literature about the application of VR and AR in medical training, an advanced search was used in this step.

2.1.2. Inclusion and Exclusion Criteria

The theory of population, intervention, comparison, and outcome (PICO) [29] was changed [30] slightly to manage the inclusion criteria and exclusion criteria of this study as shown in Table 2. In addition, literature reviews, non-English literature, and literature not available in full text online were excluded.

2.1.3. Manual Screening

The criteria for inclusion and exclusion served as a reference for manual screening. The articles found in the databases were further screened according to the title and abstract. The full-text articles were assessed in the next step to exclude irrelevant articles and the same articles from different databases. In addition, some literature might be identified in the articles’ reference lists. The overall screening process was produced as a PRISMA flowchart shown in Figure 2.

2.2. Questionnaire Survey

To answer RQ4, we conducted a questionnaire survey to hear from more authentic voices from LMICs. The survey focused on the expectations for the use of immersive technology tools, such as VR and AR. It was given to two student groups: Egyptian medical students from New Giza University and Ghanaian medical students from Kwame Nkrumah University of Science and Technology since these students would be the future main medical force in LMICs. Their views would have a significant impact on 3D virtualisation in local medical education.
To develop the questionnaire for this review, we referred to the existing literature and research methods. The study by Marvin Mergen and colleagues [31] on integrating Virtual Reality into medical curricula provides a comprehensive survey structure that includes demographic data, prior VR experience, and expectations regarding the inclusion of VR in medical training. This framework helped us design questions that assess the target group’s attitudes and needs regarding immersive technology. The questionnaire was divided into three sections: (1) Background information: This section included the respondents’ year of study, specialty, and learning experience. (2) Core questions: This section involved specific views and expectations on the use of VR and AR technologies in different medical disciplines. For example, questions were asked about the perceived benefits of using VR in anatomy or surgical training. (3) Concluding questions: This section covered overall opinions and future expectations for the use of these technologies, such as the willingness to adopt VR and AR in daily medical practice and the anticipated challenges.
A total of 26 Egyptian medical students and 9 Ghanaian medical students participated in this survey, all of whom had been studying for 2–5 years, which ensured that they had a certain degree of medical learning experience rather than just being beginners.

3. Results and Analysis

This section includes the presentation and analysis of the results of the identified literature and the questionnaire survey. The research questions serve as a framework for this section.

3.1. Literature Review

Following adherence to our inclusion and exclusion criteria, a total of 18 articles were shortlisted after screening (as shown in Figure 2). In fact, there has been a significant increase in the number of publications in this domain since 2017 as evidenced by Figure 3. This trend coincides with the major consumer releases of affordable VR/AR devices in 2016, such as the Oculus Rift, Microsoft HoloLens, and HTC Vive, along with the increasing accessibility of mobile technology [32,33]. Of course, this progress has been fuelled by the continuous increase in GPU computational power over the years. GPU computational power in Gigaflops (GFlops) has been steadily rising since 2010, driven by advancements in nanofabrication process technology, which progressed from 40 nm to 16 nm in 2016 [34]. This trend continues with the current 3 nm process technology [35], promising to produce life-like VR experiences. As the cost of immersive technology decreases, it becomes more accessible to institutions and individuals in LMICs. This lowered barrier to entry enables medical training programs in these regions to consider VR and AR as viable options.
According to our shortlisted articles, most of the studies related to the application of VR and AR for medical training in LMICs took place after 2016 and only one study was conducted in 2010 by Debes et al. [36]. This 2010 study was excluded from consideration since the equipment used was different from the portable headset technology commonly associated with VR and AR. Therefore, the characteristics of the remaining 17 research studies are presented in Table 3.
The distribution of the immersive technology employed by the investigations in these papers is displayed in Figure 4. More than half of the studies (11 studies) applied VR to medical training in resource-limited situations, while 7 studies employed AR in medical training, and only 1 study took both VR and AR into consideration. The usage mode of the immersive technology can be classified into two groups: direct mode and telementoring. Direct mode means the participants could gain knowledge or train their skills directly. Telementoring means that when the participants are conducting their training, assistants or professors could use the telecommunication device to provide guidance. It could be noticed that VR tended to utilise direct mode, while AR preferred telementoring. This could be as a result of AR technology’s ability to overlay data or visuals in real time, which makes it simpler for specialists to lead participants. As for which mode is more productive and profitable in LMICs, it has not yet been researched in the present era.

3.1.1. Medical Disciplines with VR and AR

(RQ1. What medical disciplines in training do immersive technology currently apply to?)
When it comes to the application field of VR and AR, most of the studies (10 studies) focused on the training of surgical skills, while other applications, such as anatomy and human interpersonal behaviour, only appeared once (Figure 5). Figure 6 presents the different medical disciplines in which VR and AR exist. The two most frequently occurring disciplines in this study are general surgery and urology, while the occurrence of other disciplines (gynaecology, cardiology, neonatology, oncology, and otolaryngology) is much lower, demonstrating the importance of these two disciplines in the medical education of LMICs. It should be noted that the medical discipline is classified manually, as some surgery does not exclusively belong to a certain discipline. Laparoscopic surgery and minimally invasive surgery could be used for various disciplines. At present, laparoscopic surgery has a wide range of indications and can be used for many gynaecological, urological, and general surgical diseases [26,36]. Further, minimally invasive surgery is a common concept and is suitable for numerous diseases [23]. Even laparoscopic surgery could be viewed as a kind of minimally invasive surgery, as the size of the small incision tends to be 0.5–1 cm.
Before 2019, the primary focus of studies was on using VR and AR for surgical training, aiming to enhance the proficiency of medical students and professionals in performing various surgical procedures. Additionally, a few studies began to explore the use of VR in teaching medical imaging [37], aiming to improve the imaging interpretation skills. Between 2019 and 2021, the application fields of VR and AR expanded beyond surgical training to include neonatology [43] and cardiology [41]. These disciplines started recognising the potential benefits of immersive technologies for training purposes. Furthermore, a few studies began exploring the use of VR for patient education [41] and nurse training [24,43], indicating an expanding scope, aiming to improve the knowledge and skills of patients and nursing staff through immersive experiences. From 2021 to 2023, the use of VR and AR in medical training saw a significant increase across multiple disciplines, particularly in oncology [47] and otolaryngology [46]. These technologies were leveraged to provide comprehensive training solutions spanning various medical specialties. More studies also focused on the comprehensive application of VR and AR, covering a wide range of training scenarios from anatomy to surgical skills, aiming to offer a complete training experience that enhances both theoretical knowledge and practical skills. This trend reflects the growing recognition of the value of immersive technologies in enhancing medical education and training outcomes.

3.1.2. The Necessity of VR and AR

(RQ2. Is it necessary to use VR and AR in LMICs for medical education?)
Table 3 demonstrates that most of the studies agree on the effectiveness of VR and AR in medical education in resource-limited situations. The only exception [41] that provided a negative answer had a complex situation. It claimed that VR technology increased programme adherence, but on the other hand, it reduced patients’ motivation and absorption.
Before 2019, studies such as Wang et al. [37] highlighted the potential of VR and AR technologies to enhance the continuity of treatment, decrease the frequency of medical visits, and improve access to primary and professional health services. During this period, there was an emerging recognition of the feasibility and acceptability of immersive technologies in medical training, particularly in resource-limited settings. Between 2019 and 2021, more comprehensive studies were conducted. Studies like Bala et al. [42] demonstrated the effectiveness of remote access mixed reality tools in delivering medical training. These technologies were found to be attractive, as they could provide 3D perspectives in almost any direction, making them highly effective for the technical skill development in surgery [39,40]. From 2021 to 2023, the research further solidified the necessity of VR and AR in medical education within LMICs. Studies such as Pears et al. [21] showed that immersive technologies are not only feasible and acceptable but also highly effective for patient communication. These studies highlighted that VR and AR could help with both technical and non-technical skills, increasing the overall confidence and competence of medical interns.

3.1.3. Evaluation Methods for VR and AR in Medical Training

(RQ3. What evaluation methods are used to measure the effectiveness of VR and AR for medical training in LMICs?)
Most of the screened articles have no more than two evaluation methods for VR and AR in medical training (11 articles with one method, 5 articles with two methods), while 2 articles lack clarity in their evaluation methods [38,47]. The overall evaluation methods in the screened articles are shown in Figure 7. In terms of evaluation methods, the research since 2017 has not changed much. Questionnaires and skill tests have always been the mainstream. It should be noted that the bubble chart has the same horizontal and vertical axes, and the coordinate value of one bubble represents the two evaluation methods used in the specific article. Furthermore, if one bubble’s horizontal coordinate equals its vertical coordinate, it means there is only one evaluation method in that article. The size of the bubble shows the number of articles that use the same types of evaluation methods.
A total of six evaluation methods are identified in this study: observation, self-assessment, questionnaire, semistructured interview, skills test, and knowledge test. Among the evaluation methods, only the semistructured interview is a qualitative method based on grounded theory [44]. This research strategy can openly collect the views and attitudes of participants towards the application of VR and AR in medical education while effectively summarising and extracting the results. Bing et al. [44] identified five main topics related to VR in medical education from the interview, goals, non-technical skills and technical skills development, skill transfer, barriers, and recommendations, that could indicate the research direction or framework for subsequent research. Others belong to quantitative methods. Using these quantitative methods to assess the efficacy of VR and AR in medical education could provide a clearer picture of performance variations pre- and post test. However, it should be noticed that, except for the skills test and knowledge test, there is a certain degree of subjectivity in other evaluation methods. In total, 7 out of 17 articles utilised the skill test to prove the objectivity of their results. Questionnaires are the second most commonly used research method, which might be a result of the method’s ability to gather user experiences in a more transparent manner and to gather and analyse data faster. In addition, all of the studies conducted their experiments with the strategy of a ‘control group’. Through the control group experiments, they could make a comparison between the effects before and after using this method.

3.2. Questionnaire Survey

Requirements of LMICs: (RQ4. Which medical disciplines in LMICs require immersive technology the most?)
When asked about the familiarity of VR and AR, 62.8% of all students believe that they have used or seen 3D visualisations driven by immersive technology (like 3D models or interactive simulations) in some classes. On the other hand, 22.8% of students are still inexperienced with this mode.
Figure 8 demonstrates the medical students’ attitudes towards the effectiveness of VR and AR in helping students understand difficult concepts compared to traditional 2D illustrations on a scale from 1 to 5. The majority of the participants believe that immersive technology can be helpful. These medical students also share the topics that they believe were the hardest to visualise and understand using only textbooks or 2D illustrations during their studies, which can be seen in Figure 9. More than 70% of students from both countries believe that anatomy and surgical techniques were the most difficult in that respect.
When asked about their preferred approach to studying, the results differed between Egyptian and Ghanaian students. As shown in Figure 10, the majority of students from Egypt believe that the best method to retain information is through practical, hands-on training. On the other hand, in Ghana, their preferences are more diverse, with a majority of 44.4% expressing that videos are the best method to learn new information. Their inexperience with VR technology and reservations about utilising it for medical education could be the cause of this phenomenon.
Figure 11 shows the students’ concerns about using VR and AR for medical training. Accessibility is the most significant problem in both countries, with difficulty being the second most significant problem in Egypt. Upon further analysis, almost half of the Egyptian students who expressed their concern regarding the difficulty were students who were not familiar with VR technology and 3D visualisations.
Finally, the students were asked, in the case that a 3D visualisation tool is introduced to help in understanding medical and surgical topics, which features they would find most beneficial. Their response can be seen in Figure 12, where most students agreed that interactive simulations and detailed 3D anatomical models would be favourable in their educational journey. After closer examination, a noteworthy observation emerged, whereby a majority of students exhibiting familiarity with VR technology endorsed the recommendation of interactive simulations. On the other hand, students who lacked exposure to VR technology were more inclined to suggest detailed 3D anatomical models.

4. Discussion

4.1. Main Applications and Uses

Other than anatomy and surgery mentioned by the students, there is another important application, and that is human interpersonal behaviour. Also, from the results of the literature review part, it could be concluded that the main applications of VR and AR for medical training are surgery, anatomy, and human interpersonal behaviour as shown in Figure 5. Here is some detailed information about these three applications.

4.1.1. Anatomy

Traditional learning methods: Traditionally, students have had limited access to cadavers for hands-on learning [48]. To supplement their anatomical knowledge, they have frequently relied on 2D resources such as lecture slides, textbooks, and flashcards. Some early computer education software also used 2D resources for explanation and practice. Although such 2D workspaces were relatively more effective than traditional methods, working in a 3D environment may prove to be counterintuitive [49]. This often leaves a gap in understanding the intricate details and spatial relationships of body structures.
Innovations with AR/VR: With the advent of Head-Mounted Displays (HMDs) and immersive technologies, students can now delve deep into human anatomy through virtual exploration. This technology aids in grasping “threshold concepts” [50], foundational ideas in anatomy. A significant indicator of a student’s aptitude for learning anatomy is their spatial abilities. Three-dimensional structures can help with this [51,52]. The 360° views provided by HMDs unveil detailed structures, thereby enhancing comprehension. In addition, learning with HMDs has proven to be more stimulating and interactive than traditional methods [53], particularly with 3D brain structures [54]. As the integration of these technologies into medical education continues to evolve, they are setting new standards for how anatomy knowledge is delivered, making them an indispensable tool in the training of future healthcare professionals [55].

4.1.2. Surgery

Traditional training shortfalls: “See one, Do one, Teach one” was the traditional theory often used for medical training, especially for surgery [56]. It was mainly based on observation, followed by practice on actual patients [57]. This method presented risks and depended heavily on available patient cases.
AR/VR in surgical training: Virtual Reality has revolutionised this training by providing a controlled, risk-free environment. Continuous practice in these simulated settings has shown substantial improvements in surgical skill acquisition [58]. For instance, some previous studies indicate marked reductions in procedural errors [58] and improvements in instrument handling [59]. Moreover, specific surgeries like hysterectomy [39], laparoscopy [60], and total hip arthroscopy [61,62] can be practised repeatedly, ensuring mastery. In fields like ophthalmology [63,64], virtual training environments extend practical hours, offering more opportunities for skill acquisition without the need for actual patients.

4.1.3. Human Interpersonal Behaviour

Importance in medical training: Apart from technical know-how, a significant part of medical training is understanding human behaviour. Interacting with patients, understanding their concerns, and communicating effectively is as crucial as medical expertise [65].
Role of AR/VR: AR and VR training scenarios simulate interactions with virtual environments [66], allowing medical professionals to prepare for a wide range of situations. These scenarios offer a safe space to practise interpersonal skills, from breaking bad news to understanding non-verbal cues. The emphasis is on decision-making, critical thinking, and effective communication [67,68,69]. Furthermore, in high-pressure environments, like medical emergencies, clinicians can train to manage stress and ensure clear communication. These non-technical skills (NTS) are pivotal for patient care and also have a significant impact on medical outcomes [70].

4.2. Benefits

(RQ5. What is the transformative potential of VR and AR to improve medical education?)
The immersive nature of AR/VR platforms exposes students to an environment that mimics the real world, enhancing their cognitive abilities [16]. In the literature, studies have shown that with repeated practice in Virtual Reality, medical residents not only hone their surgical techniques [71] but can also achieve expert proficiency levels on many key performance metrics. For instance, our review indicated significant reductions in procedural errors, improved instrument handling, and efficiency in completing surgeries.
Traditional anatomy classes have always faced the challenge of cadaver availability. Students often resort to 2D resources like textbooks and slides to supplement their learning. This is where Head-Mounted Displays (HMDs) can revolutionise the learning experience. These devices empower students to be more proactive, allowing them to explore, understand, and grasp complex medical concepts at their own pace. It is a proven fact that active learning fosters better retention and understanding [72]. Additionally, our review spotlighted how HMDs have been extensively utilised in surgery and anatomy with impressive outcomes, like reduced surgical errors and enhanced knowledge retention [16]. In fields such as ophthalmology, where practising on actual human eyes is limited, virtual scenarios can significantly extend training hours [64].
High-stress environments, particularly during medical emergencies, demand impeccable skill and calm composure from healthcare professionals. Preparing for such high-pressure scenarios is crucial. XR training modules can replicate these intense conditions, offering clinicians a safe space to prepare for real-life challenges [73].
Furthermore, it is worth emphasising the importance of ‘threshold concepts’ in medical education. These are foundational ideas, without which students cannot progress. With immersive technologies, these concepts become more accessible [74]. Traditional 2D materials, like textbooks, often fail to provide the spatial understanding required for grasping intricate organ structures, a gap that HMDs effectively bridge.
The modern medical curriculum is voluminous, demanding students to assimilate vast amounts of information. The motivation derived from interactive and immersive 3D models can significantly elevate engagement levels, making the learning process more efficient and enjoyable [75]. Think about it: when a student can virtually dissect and explore a 3D model of the human brain, it is bound to be more captivating than simply flipping through textbook diagrams.
In conclusion, AR and VR technologies in medical education are not just about flashy visuals. They are about maximising learning opportunities, ensuring consistency in training, and preparing our future healthcare professionals for the real-world challenges they will inevitably face. Whether it is the scarcity of cadavers or the need for safe training environments, AR/VR offers practical solutions that are both effective and cost-efficient. The era of traditional, rote-based learning is giving way to a more interactive, immersive, and impactful pedagogical approach.

4.3. Problems and Limitations

As the medical students point out in the questionnaire, the most significant barrier to revolutionising medical education in LMICs by using VR and AR is the accessibility of 3D visualisation devices. However, as investment increases in this area, it will no longer be a problem in the near future [76]. Although many medical departments in LMICs now use immersive equipment for training, there are still many medical projects that still use traditional methods for training and need to be explored using VR and AR. While VR and AR can provide immersive 3D perspectives and enhance medical skills as noted by Bing et al. [39], technical issues such as hardware malfunctions, software glitches, internet issues [21], and the need for regular updates can impede their effectiveness. These technologies require robust digital infrastructure, which is not always available in LMICs.
Other problems can be attributed to certain technical deficiencies symptoms [77]. Bala and colleagues reported that it was difficult to interact when there were multiple participants because the background noise might occur simultaneously [42]. Some users have shown physical discomforts, including nausea, dizziness, and temporary vision impairment. These symptoms often occur after just 20 min of use. Specifically, the lag time and the human eye’s challenge in fixating on “artificially distant” 3D objects are identified [78].
(1) Motion sickness: While motion sickness can be mitigated by limiting head movements or leveraging higher-resolution HMDs [79], it still remains a concern for many users. Interestingly, Augmented Reality (AR) has demonstrated potential for reducing the effects of motion sickness.
(2) Lack of model detail and haptic feedback: Accurate representation and the sensation of touch are crucial in medical training. However, current XR systems sometimes fall short in these areas [80,81].
(3) Familiarisation workload: The learning curve associated with getting acquainted with XR devices can place additional strain on users [82].
(4) User experience limitations: The limited Field Of View (FOV) or the inherent weight of the devices can occasionally hamper the user experience [83,84].
(5) Device constraints: Given that a single HMD typically supports just one user, it becomes time intensive to conduct group-based experiments or training sessions [85]. Furthermore, shared devices can raise hygiene concerns, especially during health crises like the COVID-19 pandemic.

5. Conclusions

This paper aims to explore the current applications and the real requirements of VR and AR technology as medical training methods in LMICs through a literature review and a questionnaire survey. The review collects a total of 17 articles published from 2010 to 2023, analysing their focused application fields, medical disciplines, evaluation methods, benefits, and limitations. Also, the questionnaire exposes the relatively objective views of medical students in Egypt and Ghana on VR and AR in medical training.
This paper shows that the number of studies on XR technology for medical training within LMICs is relatively small. Thankfully, though, research in related fields has been steadily increasing in recent years. Most of the studies focus on surgery, but they are not fixed within specific disciplines. Maybe universal surgical skills, such as laparoscopy, are more suitable for LMICs. It should also be noted that most studies have not mentioned the economic aspects of immersive technology devices or systems. Also, NTS (non-technical skills) is another aspect overlooked by most of the existing research. In other areas where circumstances allow, employing immersive technology for the training of NTS has become a prevalent approach [86,87].
Despite the enormous potential of VR and AR, it is crucial to recognise the importance of blending these technologies with existing pedagogical methods. While VR and AR can replicate clinical scenarios, advanced communication skills and in situ simulations still require traditional approaches [88]. Certain skills, such as effective patient communication, cannot be fully imparted through immersive technologies. Only the integration of VR and AR can enable educators to focus more on other skills. What VR and AR offer, actually, is the freedom to reallocate resources, both in terms of space and faculty, to areas they are best suited for.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/virtualworlds3030021/s1, PRISMA-Checklist.

Author Contributions

Conceptualisation, X.L. and R.G.; methodology, X.L. and G.S.; formal analysis, X.L.; investigation, D.E.; writing—original draft preparation, X.L.; writing—review and editing, G.S.; visualisation, X.L., D.E. and G.S.; supervision, R.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was approved by the Ethics Committee of College of Science and Engineering, University of Glasgow (Application Number: 300230176).

Informed Consent Statement

Informed consent was obtained from all particpants involved in the study.

Data Availability Statement

No new data were created or analysed in this study.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Snapshots of current VR and AR applications in LMICs. (a) Human interpersonal behaviour: Non-technical skills training by reflection questions (reproduced with permission [21]. Copyright 2023, Elsevier). (b) Anatomy: Tetralogy of Fallot Colour VR model of the heart (reproduced with permission [22]. Copyright 2023, Springer). (c) Surgery: View of virtual operating theatre (reproduced with permission [23]. Copyright 2019, ecancer Global Foundation). (d) Telementoring: Remote annotate images in surgeon’s visual field (reproduced with permission [24]. Copyright 2018, Wolters Kluwer Health). (e) Augmented Reality 3D annotations (reproduced with permission [25]. Copyright 2020, Elsevier). (f) VR system for laparoscopic surgery training (reproduced with permission [26]. Copyright 2021, Springer).
Figure 1. Snapshots of current VR and AR applications in LMICs. (a) Human interpersonal behaviour: Non-technical skills training by reflection questions (reproduced with permission [21]. Copyright 2023, Elsevier). (b) Anatomy: Tetralogy of Fallot Colour VR model of the heart (reproduced with permission [22]. Copyright 2023, Springer). (c) Surgery: View of virtual operating theatre (reproduced with permission [23]. Copyright 2019, ecancer Global Foundation). (d) Telementoring: Remote annotate images in surgeon’s visual field (reproduced with permission [24]. Copyright 2018, Wolters Kluwer Health). (e) Augmented Reality 3D annotations (reproduced with permission [25]. Copyright 2020, Elsevier). (f) VR system for laparoscopic surgery training (reproduced with permission [26]. Copyright 2021, Springer).
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Figure 2. PRISMA flowchart [27] for systematic reviews.
Figure 2. PRISMA flowchart [27] for systematic reviews.
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Figure 3. Number of research studies on applications of VR and AR for medical training in resource-limited situations.
Figure 3. Number of research studies on applications of VR and AR for medical training in resource-limited situations.
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Figure 4. Research divided by category and usage mode of immersive technology.
Figure 4. Research divided by category and usage mode of immersive technology.
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Figure 5. Medical application of VR and AR. Image shows that “surgery” is the most common application.
Figure 5. Medical application of VR and AR. Image shows that “surgery” is the most common application.
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Figure 6. Medical disciplines that have used VR or AR, with surgery (32%) being the most popular, followed by cardiology (12%), neonatology (12%) and urology (12%).
Figure 6. Medical disciplines that have used VR or AR, with surgery (32%) being the most popular, followed by cardiology (12%), neonatology (12%) and urology (12%).
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Figure 7. Evaluation methods for VR or AR in medical training.
Figure 7. Evaluation methods for VR or AR in medical training.
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Figure 8. Perceived benefits of VR and AR, on a scale of 1 to 5, in comparison to traditional 2D illustrations.
Figure 8. Perceived benefits of VR and AR, on a scale of 1 to 5, in comparison to traditional 2D illustrations.
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Figure 9. Topics that are challenging to visualise and understand using only textbooks or 2D illustrations. According to student responses, anatomy and surgery were most challenging.
Figure 9. Topics that are challenging to visualise and understand using only textbooks or 2D illustrations. According to student responses, anatomy and surgery were most challenging.
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Figure 10. Preferred learning modality according to two different LMIC countries (Egypt and Ghana).
Figure 10. Preferred learning modality according to two different LMIC countries (Egypt and Ghana).
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Figure 11. Barriers and concerns about using VR and AR in medical education.
Figure 11. Barriers and concerns about using VR and AR in medical education.
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Figure 12. Suggestions on immersive technology applications in medical education.
Figure 12. Suggestions on immersive technology applications in medical education.
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Table 1. Search terms used in the systematic review.
Table 1. Search terms used in the systematic review.
ConceptsImmersive TechnologyMedical DisciplineTraining MethodsResource-Limited
KeywordsAR,
VR,
MR,
XR		Anatomy,
Surgery,
Physiology,
Pathology,
Pharmacology,
Biochemistry		Training,
Education,
Simulation,
Telementoring		LMICs,
Low-and-middle-income areas,
Rural-and-remote,
Resource-limited
Table 2. PICO framework of the systematic review.
Table 2. PICO framework of the systematic review.
FrameworkDescriptionInclusionExclusion
PopulationMedical staff in resource-limited areasMedical interns,
medical students,
surgeons,
nurses		No resource-
limited situations
InterventionMedical training using immersive technology devicesAR, VR,
MR, XR		Non-immersive technology
ComparisonThe comparison of the effectivenessOnly the evaluation of the immersive technology devices,
comparisons		No evaluation of the immersive technology devices
OutcomeNegative or positive attitudesNew XR system,
evaluation		No outcome
Table 3. Shortlisted articles included in our systematic review.
Table 3. Shortlisted articles included in our systematic review.
No.YearLocationXRDeviceApplicationDisciplineSample SizeEffect-IvenessEvaluation TypeReference
12017Canada *ARHoloLensMedical imagingNon-specific24+Questionnaire[37]
22018ZambiaVROculus RiftSurgeryGeneral surgery10+Skills tests, Observation[23]
32018GazaARN/ASurgeryGeneral surgeryN/A+N/A[38]
42018Mozam-biqueARGoogle GlassSurgeryGeneral surgery12+Questionnaire[24]
52019US *ARSTAR (Hololens)SurgeryGeneral surgery20+Skills tests, self-assessment[25]
62019ZambiaVROculus RiftSurgeryGeneral surgery10+Skills tests[39]
72020ColombiaVRSIMISGEST-VRSurgeryMinimally invasive surgery ***148+Skills tests[40]
82020BrazilVRN/ARecoveryCardiology61-Observation[41]
92021UK *ARHoloLens 2Ward roundNon-specific11+Questionnaire[42]
102021Nigeria, KenyaVRN/AOtherNeonatology274+Skills tests, Knowledge tests[43]
112021ZambiaVROculus RiftSurgeryGeneral surgery11+Semistructured interviews[44]
122022Nigeria, KenyaVRN/AOtherNeonatology179+Skills tests[45]
132022The Netherlands *VRPoLaRSSurgeryLaparoscopy **38+Questionnaire, skills tests[26]
142023UK *VRN/AHuman interpersonal behaviourUrology32+Questionnaire[21]
152023USA *AR, VRZspaceAnatomyCardiology27+Questionnaire[22]
162023Finland *VRHTC Vive ProSurgeryOtolaryngology30+Skills tests, self-assessment[46]
172023IndiaARMicrosoft Hololens 2SurgeryOncologyN/A+N/A[47]
* The study was based on resource-limited situations. ** The surgery can be applied to gynaecology, urology, and general surgery. *** The surgery can be applied to all medical disciplines.
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Li, X.; Elnagar, D.; Song, G.; Ghannam, R. Advancing Medical Education Using Virtual and Augmented Reality in Low- and Middle-Income Countries: A Systematic and Critical Review. Virtual Worlds 2024, 3, 384-403. https://doi.org/10.3390/virtualworlds3030021

AMA Style

Li X, Elnagar D, Song G, Ghannam R. Advancing Medical Education Using Virtual and Augmented Reality in Low- and Middle-Income Countries: A Systematic and Critical Review. Virtual Worlds. 2024; 3(3):384-403. https://doi.org/10.3390/virtualworlds3030021

Chicago/Turabian Style

Li, Xi, Dalia Elnagar, Ge Song, and Rami Ghannam. 2024. "Advancing Medical Education Using Virtual and Augmented Reality in Low- and Middle-Income Countries: A Systematic and Critical Review" Virtual Worlds 3, no. 3: 384-403. https://doi.org/10.3390/virtualworlds3030021

APA Style

Li, X., Elnagar, D., Song, G., & Ghannam, R. (2024). Advancing Medical Education Using Virtual and Augmented Reality in Low- and Middle-Income Countries: A Systematic and Critical Review. Virtual Worlds, 3(3), 384-403. https://doi.org/10.3390/virtualworlds3030021

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