The initial search returned 3,988 items, of which 1,588 were duplicates. The remaining 2,400 papers were reviewed by title and abstract for relevance, with eight items then screened against eligibility criteria. Of these, three were found to be pertinent with a further four identified through subsequent forward and backward citation searching. Seven papers meeting the inclusion criteria were included with two linked publications, reporting on the same study but focusing on different outcomes [39, 40]. These will be referred to separately for the purposes of discussing methods and outcomes.
The final seven papers involved a range of HCP audiences, including PCPs [39,40,41], nurses [42,43,44], physicians [42, 43], genetic counselors , and medical students . Three (four papers) of the six interventions used a randomized study design [39,40,41, 44]. Table 1 summarizes the extracted data from each study.
One intervention utilized a web-based platform [39, 40], with the remaining five adopting face-to-face approaches [41,42,43,44,45] of traditional lecture formats [41,42,43,44,45], counseling role play scenarios [41,42,43,44], risk assessment practice [42,43,44], lab experience , patient discussions , and mentorship .
The training focused on topics such as communication/counseling skills [39,40,41,42,43,44,45], genetic testing principles [39, 40, 42,43,44,45], psychosocial and ethical, legal, and social issues (ELSI) [39, 40, 43,44,45], hereditary cancers/BRCA [41,42,43, 45], and risk assessment [39, 40, 44].
Interventions provided face-to-face were either completed in one day , over multiple days up to two weeks [42,43,44], or a longer expanse of time . The web-based intervention took six hours to complete [39, 40].
Across the papers, the most common outcome assessed was communication skills but there was a lack of specificity as to what this comprised [39,40,41, 43, 45]. There was an inconsistency as to whether communication outcomes referenced process work or the correct dissemination of information. For those studies that used standardized patients (SPs) to assess candidate performance, both elements of communication skills were referenced [39, 40, 45]. In one intervention, counseling skills were assessed before and after the training using a knowledge test, including items about the competences required during counseling and for disclosure of test results. Skills relating to counseling prior to genetic testing significantly improved, while those concerning test results significantly decreased post intervention . While practice sessions were included within the intervention, there was an absence of information as to the specific communication elements imparted. Other studies captured communication skills via knowledge or efficacy measures, again without clear detail on content [42, 44].
Self-efficacy and confidence were reported as outcomes in four studies [40, 43,44,45]. This was sometimes described as confidence in counseling practice  or clinical skills efficacy . In other studies, self-efficacy was broadened to include concepts such as assessing risk, drawing a pedigree, obtaining a medical history, interpreting results, and discussing screening [44, 45]. In general, self-efficacy scores significantly improved between pre and post intervention [40, 43,44,45]. Two papers with a comparator arm [40, 45] reported significant between group differences; however, only one reported post-intervention scores for both groups rendering it impossible to assess the true impact of the intervention .
Similarly, knowledge was assessed in four studies with tests covering topics such as genetic testing, shared decision making, ELSI, cancer genetics, and hereditary syndromes including breast cancer [40, 42, 43, 45]. One study compared knowledge scores pre and post attendance in both the intervention and control arms . While neither arm improved on shared decision making, both had significant improvements in overall knowledge and subsets of BRCA genetics, breast cancer, and ELSI, with further significant improvements in the intervention arm for understanding genetic test ordering and general genetics. Two papers report significant gains in overall knowledge  . One further study used a knowledge test but did not provide the scores within the current paper .
Four papers reported participant satisfaction with the training program [40,41,42, 45], often evaluated at the end of the program apart from one that assessed clarity of instruction, realism, and overall usefulness following each SP visit . In another study, 95% of participants cited continued use and benefit from the course material . A further paper noted that 12/35 attendees completed course feedback; most wanted more counseling practice with six individuals highlighting the importance of communication skills .
All studies were given a ‘weak’ global rating on the EPHPP (two or more of the six categories scored as ‘weak’), though studies did receive some ‘moderate’ and ‘strong’ scores in individual categories. No study outlined randomization procedures. Only one received a ‘moderate’ score for selection bias as there was enough information to assume the intervention group were similar to the target population . Two studies reported group differences, or confounders, between the intervention and comparator at baseline [40, 41]. Another two described both the reliability and validity of their measures [40, 42], with reliability mentioned in a further two reports [39, 43] and validity by one other .
The quality assessment for drop-out and withdrawal rates presented a range of scores with three papers receiving a ‘weak’ rating due to a lack of transparency of baseline numbers or low completion rates [41, 42, 45], three a ‘moderate’ rating owing to the amount of drop outs [39, 40, 44], and one paper received a ‘strong’ rating .