Trauma Training Courses and Programs in Low- and Lower Middle-Income Countries: A Scoping Review

Background Injury is the leading cause of morbidity and mortality in low- and lower middle-income countries (LMICs). Trauma training is a cost-effective way to improve injury outcomes. Several trauma programs have been implemented in LMICs; however, their scope and effectiveness remain unclear. In this review, we sought to describe and assess the current state of trauma training in LMICs. Methods We searched MEDLINE, Embase, Global Health, Cochrane Library, and ProQuest Dissertations & Theses Global for trauma training courses in LMICs. An additional gray literature search was conducted on university, governmental, and non- governmental organizations’ websites to identify trauma-related postgraduate medical education (PGME) opportunities. Results Most studies occurred in sub-Saharan Africa and participants were primarily physicians/surgeons, medical students/residents, and nurses. General and surgical trauma management courses were most common, followed by orthopedic trauma or plastic surgery trauma/burn care courses. 32/45 studies reported on participant knowledge and skills, 27 of which had minimal follow-up. Of the four studies commenting on cost of courses, only one demonstrated cost-effectiveness. Three articles evaluated post-course effects on patient outcomes, two of which failed to demonstrate significant improvements. Overall, 43.0% of LMICs have PGME programs with defined trauma competency requirements. Conclusions Current studies on trauma training in LMICs do not clearly demonstrate sustainability, cost-effectiveness, nor improved outcomes. Trauma training programs should be in response to a need, championed locally, and work within a cohesive system to demonstrate concrete benefits. We recommend standardized and contextualized trauma training with recertifications in LMICs for lasting and improved trauma care. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06283-1.


Introduction
Trauma and injury represent one of the greatest causes of mortality and morbidity globally, more than tuberculosis, HIV and malaria combined [1,2]. Despite a decreasing trend in injury-linked disability-associated life years (DALYs) worldwide, low-and lower middle-income countries (LMICs) continue to shoulder a disproportionate burden of traumatic incidents.
Limitations to appropriate trauma care and management in LMICs are multifactorial. After a lack of equipment, inadequate training and education of healthcare providers (HCPs) are the most common barrier to effective trauma care in these settings [3]. Several trauma courses have been implemented in LMICs including Advanced Trauma Life Support (ATLS); Primary Trauma Care (PTC); and Trauma Team Training (TTT).
ATLS is considered the gold standard for trauma training globally; however, the program has faced criticism for being too costly and uncontextualized for low-resource settings [4,5]. It was due to the lack of accessibility of ATLS that courses like PTC and TTT emerged. Although PTC and TTT train multidisciplinary teams, unlike ATLS which centers around surgical staff, these courses are narrower in their scope of traumatology topics. Consequently, although these courses have addressed some of the criticism faced by ATLS, there is still a debate as to their effectiveness to meaningfully reduce injury-related morbidity and mortality [6,7].
Another layer of trauma care education in LMICs is postgraduate medical education (PGME) programs, many with specific trauma competencies built into the curricula [8,9]. The restructuring and increased development of these PGME programs in LMICs are promising for the field of traumatology; however, there lacks a description of available PGME programs, limiting the ability to comprehensively evaluate trauma training systems in LMICs.
To date, there remains uncertainty as to the extent and effectiveness of trauma training in LMICs. Notably, there is no consensus as to what is the most successful, appropriate, and cost-effective program for definitive hospital care trauma training. This scoping review aims to examine the current ecosystem of trauma training in LMICs, with a specific emphasis on the effectiveness, breadth, multi-disciplinarity, and sustainability of these programs.

Methods
This scoping review was registered in Open Science Framework (OSF, osf.io/2q9d3) and reported in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis-Extension for Scoping Reviews (PRISMA-ScR) framework (Online Resource 1) [10].

Search strategy
Comprehensive searches were undertaken in Ovid MED-LINE, Ovid Embase, Ovid Global Health, Cochrane Library, and ProQuest Dissertations & Theses Global on Aug 24, 2020, using relevant keywords (Online Resource 2). Since there were major developments in global trauma training over the last 20 years, the searches were limited to articles published from 2000 and onward [11]. Gray literature, reference lists of reviews and retrieved articles, and consultations with experts were also conducted to identify additional studies.

Study and program selection
Two reviewers independently screened titles, abstracts, and full texts. Studies were included if they were experimental or observational studies and excluded if they were book chapters, conference abstracts, or non-peer reviewed. Articles pertaining to HCPs, including but not limited to physicians, surgeons, medical officers, nurses, and medical students were included, while those describing laypeople or pre-hospital care providers were excluded. All trauma courses training that focused on trauma including the management of specific injuries such as orthopedic injuries, burns, traumatic brain injuries, and craniomaxillofacial injuries were included. Studies reporting educational programs focused exclusively on ultrasound, telemedicine, triage, trauma registries, critical care, and emergency medicine (including obstetrics, neonatology, and infectious diseases) were excluded.

Data extraction and analysis
The following information was extracted from individual studies using a standardized extraction form: publication year, study setting, characteristics of trainees, course details, and course outcomes. Data from primary studies were extracted by one reviewer and independently verified by a second reviewer. Any discrepancies were resolved by consensus.
Study characteristics were analyzed and presented using a mixed-methods approach. The heterogeneous nature of this review precluded a meta-analysis. Instead, a narrative synthesis of results was undertaken using evidence tables and figures to aid in data presentation, when appropriate.
Outcomes included course effectiveness, suitability, sustainability, and breadth of topics and training. Course effectiveness was defined based on changes to patient morbidity and mortality or skills of participants. Suitability refers to the extent to which courses were contextualized to the setting and engaged local stakeholders during implementation. Sustainability reflects the longevity of the course in terms of follow-up, recertification processes and cost-effectiveness, while course breadth refers to the variety of types of HCP participants and trauma topics.
Gray literature search for PGME programs A gray literature search for surgical PGME programs with trauma components in LMICs was undertaken. Accredited programs such as residency, fellowship, diploma, certificate, Masters, and Doctoral programs were used as search terms, identified, and included for consideration. PGME programs were reviewed for trauma components and duration.

Trauma care training courses
We retrieved 4305 articles from the electronic search, of which 3095 underwent title and abstract screening. Seven studies were multiple publications reporting on the same training course or study cohort and therefore are reported with their parent study to avoid duplication, resulting in 45 unique studies (Fig. 1) . Descriptions of included studies can be found in Table 1.
Orthopedic trauma injury management was the focus of six (13.3%) studies [4,18,21,22,55,57], while burn management was the focus of four, of which two reported on the implementation of the American Burn Association/ Children's Burn Foundation (ABA/CBF) Team Training program [29,62]. Only one study reported on trauma related to plastic surgery reconstruction [44].

Course effectiveness
Most studies found an improvement in trauma management skills and knowledge, regardless of course type (32/45, 71.1%). Most of the studies reported increase in participant skills and/or knowledge of trauma management based on pre-course versus post-course tests and surveys (28/45, 62.2%), while the remaining four studies evaluated knowledge through self-reflection surveys or interviews.
Cioè-Peña et al. [19] reported a significant increase in the use of FAST exams; however, other facets of trauma management, including critical skills and time to operating room, were not significantly altered by PTC training. Ullrich et al. [60] found an improvement from pre-course to post-course test scores, but actual trauma operative management techniques did not significantly improve.
Two studies implemented and examined ABA/CBF training on burn management competencies and patient outcomes [29,62]. One study in India reported improved burn management skills, including decreased antibiotic use and earlier excision and grafting [29], while a similar study in Zambia did not report significant changes to burn management protocols or consequent patient outcomes [62].
Carey et al. [55] reported on the completion of 93.3% flaps with a 78.1% aversion rate of amputations, while Tajsic et al. [13] indicated a 70% primary healing rate of open fractures after orthopedic trauma courses. Participants of the Uganda Sustainable Trauma Orthopedic Program reported a subjective improvement for patients with orthopedic trauma [58]. Additionally, the orthopedic trauma PGME program in Malawi and Haiti demonstrated a significant improvement in patient outcomes post-training [21,51].
ATLS training significantly decreased mortality of severely injured patients in Rwanda [52]. PTC training in El Salvador, and ABA/CBF training in Zambia did not result in improved patient mortality rates post-training [19,62].   (6) Nurses (2) The orthopedic training fellowship workshop on trauma care received high satisfaction ratings from participants in terms of satisfaction of teaching tools (4.28/5); perceived benefit of course (4.17/ 5) and overall quality of the workshop (4.32/5) Residents (21) Physicians (9) Other (11 Physicians (32) Nurses (22) EMTs (10) Medical students (5) Survey responses indicated that the course was satisfactory but needed adjustments for LMICs to include unavailability of specialists and increased nursing responsibilities Pringle, 2015 [24] Nicaragua ''Short trauma course with low cost simulation'' Physicians (18) Residents (15) Written Trauma knowledge quiz scores demonstrated that the net pass rate for those who completed ATLS was 97% compared to 15% for those who did not take ATLS

Sustainability
In total, 4/45 (8.9%) studies commented on course costs [14,21,55,56], of which only one study examined costeffectiveness of the course teachings versus traditional care [21]. The TTT workshops in Uganda were the most inexpensive, costing $700-1,000 USD/course, after an initial $2,000 USD was spent on equipment [56]. The Surgical Management and Reconstructive Training orthopedic trauma course in Tanzania was more expensive, with an annual cost of $18,000-25,000 USD [55]. A Mongolian ATLS study emphasized the benefit of training local staff as instructors, as annual course costs decreased from $68,038 USD to $10,709 USD when Mongolian trainers were used [14]. Carlson et al. [21] were the only study to report on the cost-effectiveness of their Orthopedic Trauma Care Specialist program, which resulted in cost savings of $134 USD per DALY per resident trained as an orthopedic trauma specialist surgeon.
In total, five studies followed participant outcomes for a period of at least six months, with only one study following up for greater than one year [45]. No studies described a recertification process. The two studies comparing retention of knowledge several months after course administration reported retained competencies in trauma knowledge and skills at nine months [49] and two years [45]. None of the studies examined long-term patient mortality and morbidity for a period greater than one year, nor compared results to pre-course parameters.

Postgraduate medical education programs
In total, 51/79 (64.6%) of LMICs have a form of surgical PGME program, of which 34 (66.7%) define trauma skills as required curricular competencies (Fig. 2). These countries have formalized PGME programs in the form of residencies, fellowships, and Masters and/or Doctorates. Traumatology is most often a component of general surgery or orthopedic surgery PGME programs (Online Resource 3). Other PGME programs with required trauma competencies include neurosurgery, cardiothoracic surgery, pediatric surgery, maxillofacial surgery, urology, otorhinolaryngology, and plastic surgery. Most PGME programs are two to five years long, but time devoted to trauma training varies greatly between programs.
Several countries belong to an overarching professional society that regulates PGRME programs. In sub-Saharan Africa, this includes the College of Surgeons of East, Central, and Southern Africa (COSECSA) [8] and the West African College of Surgeons (WACS) [64]. The Arab Boards also regulate and accredit PGME programs in the Middle East, South Asia, and North Africa [65]. Although the American College of Surgeons (ACS) does not oversee PGME programs in LMICs, they do provide continuing medical education (CME) opportunities for trainees. Nurses (64) The study describes the first successful and sustainable implementation of ATCN/ATLS at a nursing college in Bulawayo

Discussion
To our knowledge, this is the first review to provide a comprehensive overview of trauma training in LMICs, including both trauma courses and PGME programs. Overall, we discovered several attempts to implement various trauma training courses in LMICs, but there is little and conflicting evidence concerning the effectiveness, suitability, and sustainability of these courses long-term (Fig. 3).

Inadequate needs assessments
Most of the studies attempted to engage locals when implementing trauma courses. However, only 15 studies conducted a formal needs assessment with their target populations. Successful trauma systems in LMICs include predevelopment needs assessments that identify existing resources and serve as a foundation for future developments [66]. Future studies should include formal needs assessments with stakeholders and may include methods such as the literature reviews, community surveys, focus groups, cross-sectional observations, chart reviews, or a combination [66]. However, although formal needs assessments were not conducted, several of the courses likely enshrined local engagement into their processes through longitudinal interactions with these populations and partnerships with LMIC colleagues.

Lack of course standardization
Although many LMICs have PGME programs with trauma management competencies, the distribution, duration, and structure of these programs vary across countries and regions. These inconsistencies are further compounded by some countries belonging to multiple PGME regulatory organizations, resulting in different standards of accreditation for trainees in different specialties or hospitals across a given country. A cohesive and sustainable approach to trauma training, either regionally, nationally, or inter-regionally, has the opportunity to reduce costs and improve standardization and quality of education for HCPs involved in trauma care management.

Indeterminate ''best'' trauma course
A reason for the lack of guidance on mandatory trauma courses may stem from uncertainty as to the most beneficial trauma course for LMICs. Contributing to the uncertainty in course superiority is the fact that studies have failed to demonstrate equal or improved care by alternative courses in LMICs compared to ATLS, the current gold standard for trauma training in HICs [67]. The fact that the two non-ATLS courses reporting on changes in patient mortality revealed no significant difference in pre-course and post-course patient outcomes creates a question to the utility and validity of these courses in trauma education [19,62]. ATLS was the only program to demonstrate concrete mortality benefits to injured patients; however, ATLS lacks a multidisciplinary approach that reflects the reality in LMICs. Rural Trauma Team Development Course (RTTDC) is also offered by the ACS and provides multidisciplinary trauma training and emphasizes teamwork and crisis resource management and has shown success in improving outcomes in rural settings [68]. Only one study looked at RTTDC implementation and did not link course participation to patient outcomes. However, a hybrid model of RTTDC and ATLS combining the multidisciplinary and resource management components of RTTDC with the high standards and quality of training of ATLS may be beneficial in these regions.
The lack of cost-effectiveness data of courses further adds to the ambiguity surrounding their appropriateness in an LMIC setting. Several previous studies have claimed the expensive nature of ATLS, along with reliance on highincome equipment, and make the course unsuitable for use in LMICs [52]. However, we have found a lack of evidence to support the cost-effectiveness of other trauma training courses in LMICs. Evidently, a robust health economics evaluation of the different programs, models of training, resource utilization, and patient outcomes are needed before conclusive statements on course cost-effectiveness can be made.
Overall, limitations in course evaluation with respect to cost-effectiveness and clinical outcomes can be partially attributed to the insufficient follow-up time of the studies. An essential component to CME is the process of recertification, something enshrined in the ATLS model and recommended in the WHO's Guidelines for trauma quality improvement programs [69]. None of the included studies mentioned a recertification process for participants after taking a stand-alone trauma course. This brings up an issue of sustainability and ethical responsibility to ensure trainees have opportunities to refresh their knowledge and skills, representing an area of needed improvement in trauma training in these regions. There is a substantial lack of funding for global surgery initiatives, and many of these courses are paid for through donations. A stronger global surgery funding network would bolster the scientific rigor of this subject and allow for improved outcome measurements, including longer follow-up periods.

Limitations
These findings should be interpreted with respect to limitations of this study. This review was only able to capture information on trauma programs published online. Furthermore, the search strategy was conducted in English and therefore may have missed articles or websites in different languages. Consequently, PGME programs may exist that were not identified. Additionally, available websites for PGME programs may not be up to date or reflect actual functioning of the programs.
NGOs such as Médecins Sans Frontières and the International Committee of the Red Cross train HCPs during their deployments in trauma care. These trainings are not typically published as research articles and traditionally rely on HCPs from HICs and therefore were outside of the scope of this review. However, these organizations are increasingly providing multidisciplinary trauma training to local practitioners and are important collaborators and funders of trauma training in LMICs.
Furthermore, we excluded laypeople trained in trauma care. Laypeople play an important role in trauma management in LMICs, especially in rural and pre-hospital settings [70]. However, in an attempt to succinctly define parameters of this study, we chose to focus exclusively on trained HCPs providing definitive trauma care. This narrowed the scope of our results, providing a reductionist picture of the trauma care as a whole in LMICs.

Conclusion
This scoping review is the first known study to provide a comprehensive examination of trauma training opportunities, including PGME programs in LMICs. Overall, this study has illuminated the notable lack of standardization and evidence-based implementation of trauma training in these regions. It highlights the fragmentation in trauma training in many LMICs when well-intentioned players, often from HICs, introduce multiple courses without needsinformed engagement from local stakeholders. Although several different trauma courses have been executed in LMICs, studies have failed to prove long-term mortality,   Fig. 3 Number of courses demonstrating improvements in effectiveness, suitability, and sustainability of trauma training. Blue, effectiveness categories; green, suitability categories; and orange, sustainability categories morbidity, and/or economic benefits. Trauma training programs should be required to demonstrate these outcomes and establish a standardized and longitudinal process for HCP trauma certification in a given country or region. A comprehensive and effective trauma education program should include short courses like ATLS that are contextualized to the setting, incorporated into CME, and demonstrate tangible benefits to patients and the healthcare system (Fig. 4).
Authors' contributions RL, AS, and HGH designed the study. JK designed the search strategy and helped with methods. RL, XC, and SD performed the literature review and study selection. RL performed data analysis and wrote the article. AS, HGH, EJ, XC, and SD served as additional reviewers, made substantial contributions to the discussion, and critically revised the article for content. All authors read and improved the final article.
Funding The authors declare no funding.

Declarations
Conflict of interest The authors declare that they have no competing interests to disclose.
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