A review of training opportunities for ultrasonography in low and middle income countries
Corresponding Author Reinou S. Groen, Surgeons OverSeas, 225, 6th Street, Suite 7F, New York, NY 10003, USA. Tel.: +1 917 603 0479; Fax: +1 201 768 7517; E-mail: email@example.com
Objective To review the current training opportunities for ultrasound use for health workers practising in low- and middle-income countries (LMICs).
Methods A PubMed search using terms ultrasound, sonography, echocardiography, developing country/countries, developing world, low resource settings, low income country/countries, training and education was conducted. Articles from 2000 to 2011 that included data on ultrasonography training were eligible for inclusion.
Results This review shows that most ultrasound scans are performed by generalist and obstetric physicians and even non-medical personnel with little to no formal training in ultrasonography. The spectrum of ultrasonography training described spanned from no formal training to formal certification and residency programmes. All courses included some component of didactics and hands-on training. Follow-up of trainee skills ranged from none, to telemedicine case review, to formal re-evaluations and intensive refresher courses. Ultrasonographic training in LMICs often does not meet the WHO criteria such as the number of scans under supervision and length of training programme recommended by WHO. Nevertheless, some programmes manage to have excellent outcomes with regard to diagnostic accuracy and retention of knowledge by trained personnel.
Conclusion Regulation and quality control of training in ultrasound skills for those working in LMICs can be improved. Research on effective training and follow-up should be encouraged.
Objectifs: Examiner les opportunités actuelles de formation dans l’utilisation des ultrasons pour les agents de la santé exerçant dans les pays à ressources faibles et intermédiaires (PFR-PRI).
Méthodes: Une recherche a été menée sur PubMed utilisant les termes suivants: ultrason, échographie, échocardiographie, pays en développement, monde en développement, pays à ressources faibles, pays à ressources élevées, formation, éducation. Les articles de 2000 à 2011 comportant des données sur la formation en échographie étaient éligibles pour inclusion.
Résultats: Cette revue montre que la plupart des analyses par ultrasons sont effectuées par les médecins généralistes obstétricaux et même par du personnel non médical, avec peu ou aucune formation officielle en échographie. Le spectre de la formation en échographie décrite allait de l’absence de formation officielle à la certification officielle et à des programmes de résidence. Tous les cours comportaient des composantes théoriques et pratiques de la formation. Le suivi de la compétence des stagiaires variait de nul à l’analyse des cas par télémédecine, à la réévaluation officielle et à des cours intensifs de recyclage. La formation en échographique dans les PFR-PRI ne répond pas souvent aux critères de l’OMS tels que le nombre de balayages sous supervision et la durée recommandée du programme de formation. Néanmoins, certains programmes parviennent à obtenir d’excellents résultats pour ce qui est de la précision du diagnostic et du maintien des connaissances par un personnel formé.
Conclusion: La règlementation et le contrôle de qualité de la formation dans les compétences aux ultrasons pour ceux qui travaillent dans les PFR-PRI peuvent être améliorés. La recherche sur la formation effective et le suivi devraient être encouragée.
Objetivos: Revisar las oportunidades actuales de entrenamiento en el uso de ultrasonido para sanitarios trabajando en países de ingresos medios y bajos (PIMBs).
Métodos: Búsqueda en PubMed utilizando las palabras: ultrasonido, sonografía, ecocardiografía, país / países en vías de desarrollo, mundo en vías de desarrollo, emplazamiento con bajos recursos, entrenamiento, educación. Los artículos encontrados pertenecientes a los años 2000 a 2011 que tenían datos sobre entrenamiento en ultrasonografía eran elegible para inclusión.
Resultados: Esta revisión muestra que la mayoría de los escáneres de ultrasonido son realizados por médicos generalistas y obstetras, e incluso por personal no médico, con poco o ningún entrenamiento formal en ultrasonografía. El espectro de entrenamiento en ultrasonografía descrito iba desde el entrenamiento no formal a la certificación formal y programas para residentes. Todos los cursos incluían algunos componentes de didáctica y entrenamiento práctico. El seguimiento de las habilidades del aprendiz iba de absolutamente ninguno a una revisión de casos telemática, o a re-evaluaciones formales y cursillos intensivos de actualización. El entrenamiento en ultrasonografía en PIMBs a menudo no cumple con los criterios de la OMS, como en el número de escáneres bajo supervisión o en la duración de los programas de entrenamiento. Sin embargo, algunos programas consiguen tener resultados excelentes en lo que respecta a la precisión diagnóstica y la retención de conocimientos del personal entrenado.
Conclusión: Puede mejorarse la regulación y el control de calidad del entrenamiento en ultrasonido, de quienes trabajan en PIMBs. Debería fomentarse la investigación para un entrenamiento efectivo y su seguimiento.
According to the WHO, 60% of the world does not have access to any diagnostic radiological services (Group 1998). The WHO also states that ultrasound is cost-effective, safe and should be available worldwide to assist clinicians in the diagnostic process (Mindel 1997). Many of the surgical, infectious, non-communicable and obstetric pathologies that afflict populations in low- and middle-income Countries (LMICs) can be accurately and cost-effectively diagnosed with ultrasound. Ultrasound is currently most frequently used for obstetrics and has the potential to change clinical management in at least 30% of cases (Groen et al. 2011). Nonetheless, the cost of purchase, the technical skills required for maintenance and the user-dependent accuracy have limited the application of ultrasonography in resource-imited settings (Harris & Marks 2009).
As implementation strategies are devised to address the current lack of access to adequate diagnostics, it is important that emphasis be placed on adequate personnel training. In the case of ultrasound, there are multiple concerning reports of technology misuse that may be avoided with adequate training. Specifically, reports exist of inaccurate diagnoses, improper use for financial gain, and lack of understanding of the limitations of the technology with associated decrease in completion of history and physical examination (Tautz et al. 2000; Gammeltoft & Nguyen 2007b; Chigbu et al. 2008).
The review on ultrasound in LMICs by Groen et al. (2011) specifically discussed the current use of ultrasound and its measured change in clinical management; this paper will discuss the current strategies and opportunities for ultrasound training in LMICs (Groen et al. 2011).
The PubMed search by Groen et al. from December 2010 using the terms ultrasound, sonography, developing country/countries, developing world, low resource settings, low-income country/countries, training, education was complemented with a secondary search for the latest relevant literature echocardiography. Original research articles, case reports, reviews, opinions, and descriptive studies in English were included. The search was then expanded using the references of each article. All articles published between 2000 and 2011, which addressed training in ultrasound use in LMICs, were reviewed for relevance by one of the authors (LNL) to be included in this review.
Studies were selected based on whether they met at least one of two criteria. First, studies that included the identity and training of the personnel performing sonography were included. Second, studies that specifically defined ultrasound training programmes were included. Of note, if a study identified the sonographer, but that person was an expatriate who was participating solely for the study and was not involved in training, that study did not meet criteria solely based on identifying the sonographer.
Data were collected on type of research, country of origin, whether it represented a rural or urban experience, whether the author was a local of the country of origin and the medical specialty represented. Information was gathered on the identity of the ultrasonographers, their training and the follow-up to that training. Finally, the educational programmes described in the articles were further researched, primarily via institutional Web pages, with information gathered regarding host institution, trainee eligibility requirements, recruitment processes, education method, trainee volume, funding, cost, certification and contact information.
Forty-one articles met our inclusion criteria. Of these, four were reviews, six were expert opinion, two were special reports, five were descriptive social science, 17 were prospective descriptive, two were retrospective descriptive, two were case-controlled prospective trials, one was a retrospective cohort study, one was a case series and one was an open-cluster randomised trial. Articles represented multiple subspecialties; 20 articles were written by radiologists, six by emergency medicine specialists, four by internal medicine doctors, ten by obstetricians and one by a paediatrician. Fifteen countries were specifically represented, in addition to multiple multinational studies. 33% of studies were written by local authors; 28% were conducted in rural areas or refugee camps; the remainder at referral centres or mixed locations. Of the 41 included articles, seven specifically mentioned transfer of skills and 18 included some mention of non-physician sonographers (Table 1).
Table 1. Reviewed articles with details regarding operator identity and training
|Case–control||Rijken||N||2009||Obstetric ultrasound scanning by local health workers in a refugee camp on the Thai-Burmese border||Thailand||Obstetrics||F||Health workers, RN and expatriate MD (as trainer).||3-month course.|
|Bonnard||Y||2011||Learning Curve of Vesico-Urinary Ultrasonography in Schistosoma haematobium Infection with WHO Practical Guide: A ‘Simple to Learn’ Examination||Senegal||Radiology||R||‘Learning clinician’||8 days of one-on-one training with radiologist.|
|Case series||Bahu||Y||2001||Hepatobiliary and pancreatic complications of ascariasis in children: a study of seven cases||Brazil||Internal medicine||N||MD: Paediatric radiologist.|| |
|Cross-sectional descriptive||King||N||2003||Measuring morbidity in shistosomiasis mansoni: relationship between image pattern, portal vein diameter and portal branch thickness in large-scale surveys using new WHO coding guidelines for ultrasound in schistosomiasis||Egypt and Kenya||Internal medicine||N||MDs, US technicians||Review of topics with the authors.|
|Mubuuke||Y||2008||Evaluation of community-based education and service course for undergraduate radiography students.||Uganda||Radiology||R||Radiography students, graduates, teachers and tutors.||11 weeks over 2 years.|
|Experience description||Adler||N||2008||Introduction of a portable US unit into the health services of the Lugufu refugee camp, Kigoma District.||Tanzania||Emergency medicine||F||Four MDs and six clinical officers||4-day course.|
|Crouch||N||2010||Perceived confidence in the FAST exam before and after an educational intervention in a developing country.||Peru||Emergency medicine||N||MDs and RNs.||2.5-h course (during surgical conference).|
|Ferraioli||N||2007||Sonographic training program at a district hospital in a developing country, work in progress||Tanzania||Radiology||R||Radiography technicians and assistant medical officers.||30 weeks over 5 years.|
|Heller||N||2010||Short Course for Focused Assessment with Sonography for HIV/TB: Preliminary Results in a Rural Setting in South Africa with High Prevalence of HIV and TB||South Africa||Internal medicine||N||MDs: generalists.||16-h course.|
|Shah||N||2008||Development of an ultrasound training curriculum in a limited-resource international setting: successes and challenges of ultrasound training in rural Rwanda||Rwanda||Emergency medicine||R||MDs.||9-week course.|
|Shah||N||2009||Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008||Rwanda||Emergency medicine||R||MDs.||9-week course.|
|Expert opinion||Gharbi||Y||2000||Africa||Africa||Radiology||M||MDs: general, radiologist, gynaecologist and cardiologist.||General practitioners with little formal training.|
|Harris||N||2009||Compact Ultrasound for Improving Maternal and Perinatal Care in Low-Resource Settings||LMIC||Obstetrics||M||MDs||3-day to 2- to 3-week courses.|
|Harris||N||2011||Donation and Training of Medical Personnel in Compact Ultrasound in Low-Resource Settings. How We Do It.||LMIC||Radiology||R||MDs: generalists. RNs.||2-day to 2-week courses.|
|Kongnyuy||N||2007||The use of ultrasonography in obstetrics in developing countries||LMIC||Obstetrics||M||Should train midwives/RNs||‘Inadequate’. No training details provided.|
|Ostensen||N||2000||Developing Countries||LMIC||Radiology||N||MDs: generalists and radiologists. For-profit.||Recommend devel-opment of programmes.|
|Ostensen||N||2000||Diagnostic imaging in developing countries: considerations for improvement.||LMIC||Radiology||N||‘Technical and medical staff’||Launched pro-gramme to provide tailor-made training programmes.|
|Randomised trial||Van Dyk||Y||2007||Routine second-trimester ultrasound for low risk pregnancies in a South African community||South Africa||Obstetrics||N||Ultrasonographer||‘Experienced, licensed.’|
|Prospective descriptive||Baltarowich||N||2009||Effectiveness of ‘Teaching the Teachers’ Initiative for Ultrasound Training in Africa||LMIC||Radiology||T||MDs.||12-week course.|
|Bussman||Y||2001||Feasibility of an ultrasound service on district health care level in Botswana||Botswana||Radiology||R||MDs.|| |
|Goldberg||N||2001||Effectiveness of the ‘Teach the Teachers’ Diagnostic Ultrasound Training Program||LMIC||Radiology||N||MDs||12-week course.|
|Justice||N||2007||Accuracy of ultrasonography for the diagnosis of intussusceptions in infants in Vietnam.||Vietnam||Paediatrics||N||Paediatric ultrasonographers.||‘Trained’|
|Kotlyar||N||2008||Assessing the utility of US in Liberia||Liberia||Emergency||N||MDs: emergency medicine|| |
|Obajimi||Y||2008||Abdominal US in HIV/AIDS patients in SW Nigeria||Nigeria||Radiology||N||MDs: radiologists|| |
| ||Smith||N||2010||FAST scanning in the developing world emergency department.||KwaZulu-Natal||Emergency||T||MDs: emergency medicine (EM).||‘Trained at emergency US course provided by American College Of EM Physicians or British College of EM.’|
| ||Akhtar||Y||2011||Ultrasound Biosafety During Pregnancy: What Do Operators Know in the Developing World?||Pakistan||Radiology||M||MDs: radiologists, sonographers and others.||Lack of training in ultrasound safety parameters.|
| ||Kodikara||Y||2010||Evaluation of Pacific obstetric and gynaecological ultrasound scanning capabilities, personnel, equipment and workloads.||Pacific||Obstetrics||R||MDs: obstetricians, radiologists, generalists and sonographers.||Trained by WHO, radiologists or obstetricians. 37% certified in ultrasound. 40% engaged in continuing education.|
|Retrospective cohort||Kawooya||Y||2010||Evaluation of US Training for the Past 6 years at ECUREI, the World Federation for Ultrasound in Medicine and Biology Centre of Excellence, Kampala, Uganda.||Uganda||Radiology||R||MDs and ultrasonographers.||Diploma 6–12 months, 2-year bachelor’s, 2-year master’s, 3-month fast track.|
|Retrospective descriptive||Bai||Y||2006||Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years.||China||Radiology||N||Sonologist and paediatric surgeons.||Formal and ‘on-the-job’ training.|
|Chen||Y||2009||Ultrasound screening for fetal structural abnormalities performed by trained mid-wives in the second trimester in a low-risk population – an appraisal.||China||Radiology||N||Midwives||‘Certificate course under supervision of Maternal and Fetal Medicine specialist. Pass the American Registry of Diagnostic Medical Sonographers examination.’|
|Review||Goldberg||N||2003||International Arena of Ultrasound Education||LMIC||Radiology||N||MDs|| |
|Khanna||N||2008||US guided intussusception reduction: are we there yet?||LMIC||Radiology||M||MDs: paediatric surgeon and paediatric radiologist.|| |
|Rabinowitz||N||2005||Postgraduate Radiology Training in Sub-Saharan Africa: A Review of Current Educational Resources||Africa||Radiology||M||MDs.||6–8 months of rotations.|
|Richter||N||2003||Ultrasound in tropical and parasitic diseases||LMIC||Internal medicine||M||Varies||Varies.|
|Social science descriptive||Bashour||Y||2005||Syrian Women’s Perceptions and Experiences of Ultrasound Screening in Pregnancy: Implications for Antenatal Policy||Syria||Obstetrics||N||MDs: obstetricians.||‘Post-graduate training in OB, but no formal training in US.’|
|Enakpene||Y||2009||Clients’ reasons for prenatal Ultrasound in Ibadan, South West of Nigeria||Nigeria||Obstetrics||N||Sonographers and traditional birth attendants.|| |
|Gammeltoft||N||2007a,b||The Commodification of Obstetric Ultrasound Scanning in Hanoi, Viet Nam||Vietnam||Obstetrics||N||MDs||‘basic training course in ultrasonography and obtain a certificate.’|
|Gammeltoft||N||2007a,b||Fetal conditions and fatal decisions: Ethical dilemmas in ultrasound screening in Vietnam||Vietnam||Obstetrics||N||MDs: obstetricians and radiologists.||‘course in US which focused on the normal fetus. Limited supervision/assessment.’|
|Tautz||N||2000||Between fear and relief: how rural pregnant women experience foetal US in a Botswana district hospital.||Botswana||Obstetrics||R||MDs.|| |
|Special report||WHO||N||2003||International classification of US images in cystic echinococcosis for application in clinical and field epidemiologic settings.||LMIC||Radiology||M|| || |
|WHO||N||2005||Good clinical diagnostic practice||LMIC||Radiology||M|| || |
The spectrum of ultrasonography training described spanned from no formal training, to one-on-one intensive skills transfer, to formal certification and residency programmes. Many studies included scant detail regarding training specifics of the operator simply stating that the ultrasonographer was ‘experienced’ or ‘qualified’. Of formalised training programmes, several offered comprehensive basic didactic and practical training, specifically, ‘Teach the Teachers’, Partners in Health in Rwanda, sonographic training programme in Tanzania and the formal residency programmes (Table 2). Others were workshops focusing on the acquisition of a narrow skill set, that is, focused assessment with sonography for trauma (FAST), focused assessment with sonography for HIV/TB (FASH) and various ‘Projects on Education’ and lectures sponsored by the World Federation for Ultrasound in Medicine and Biology (WFUMB). The comprehensive courses spanned from 9 weeks to 8 months of training, while workshops were 1–2.5 h. All courses included some component of didactics and hands-on training. Of the formal programmes, follow-up of trainee skills ranged from none to telemedicine case review, to formal re-evaluations and intensive refresher courses.
Table 2. Training programs represented in reviewed articles
|‘Teaching the Teachers’||Jefferson Ultrasound Research and Education Institute (JUREI)||MDs who pass pre-test.||>70 centres||JUREI web, Radiological Society of N. America web, WHO, local radiological societies.||12 weeks||Examination at 6 months. MD director returns to JUREI for intense refresher after 1 year.||>3500 MDs per year||Radiology Society of N. America. International Radiology Education Program Grant||Y||http://www.jefferson.edu/jurei/affiliate/||Baltarowich, Goldberg, Goldberg, Kawooya,|
|Hospital-based Ultrasound Training Curriculum||Partners in Health||MDs||Hospital based||All local staff MD||9 weeks||Telemedicine. scans sent for review after 10 weeks.||10||Private grants.||N||Sachita.firstname.lastname@example.org||Shah, Shah|
|FAST Exam||University of Utah||Nurses and MDs.||Conference based||Voluntary attendees of trauma conference||2.5 h/1 day||None.||25||Conference fees.||Nemail@example.com||Crouch|
|Short Course for Focused Assessment with Sonography for HIV/TB.||University of KwaZulu-Natal||MDs||Hospital based||Local staff MD||16 h/2 day||None.||3||Wellcome Trust Grant||Nfirstname.lastname@example.org||Heller|
|Hospital-based Ultrasound Training Curriculum||World Medical Colours||Technicians, medical officers and MDs.||Zanzibar||Chosen by the health office of Zanzibar.||30 weeks/5 year||Telemedicine||11||Private grants.||Pemail@example.com||Ferraioli|
|http://www.sonoworld.com||SonoWorld||Open-access online source||>200 lectures, >100 cases.||Online.||1-h lectures, 2-d conferences.||Not formalised, available as pursued by practitioner.||>75,000 registered users.||Free. Sponsored by Toshiba, Siemens, Philips, GE.||N||http://www.sonoworld.com||Kodikara|
|Mediterranean and African Society of Ultrasound|| ||Open-access||Online||Online. Local radiology societies.||to 3-day conferences, workshops||NA||NA||Private grants.||N||http://www.masu-ultrasound.com/11.html||Gharbi, Harris|
|Centers of Excellence||World Federation for Ultrasound in Medicine and Biology (WFUMB)||Affiliated organisation membership||Five centres||Through affiliates.||Varies. No details provided.||Biannual renewal||Five centres||WFUMB Grant, private.||Y||http://www.wfumb.org/outreach/centers.aspx||Kodikara|
|Projects on Education, lectures||WFUMB||Affiliated organisation.|| ||Online. Local radiology societies.||1–2 h||NA||NA||WFUMB Grant||N||http://www.wfumb.org/outreach/projects.aspx||Harris|
|Radiology Residency||Korle-Bu Hospital, Ghana.||Resident MDs|| ||Course is required for graduation.||7 months/4 years||NA||13||Government salary||Y||P. O. Box 77, Korle-Bu, Accra Ghana.||Rabinowitz|
|Radiology Residency||Groote Schuur Hospital, S. Africa.||Resident MDs|| ||Course is required for graduation.||6–7 months/4 years||NA||26||Government salary||Y||http://www.westerncape.gov.za/your_gov/5972||Rabinowitz|
|Radiology Residency||Tygerberg Hospital, S. Africa.||Resident MDs|| ||Course is required for graduation.||7–8 months/4 years||NA||18||Government salary||Y||http://www.westerncape.gov.za/eng/your_gov/5987||Rabinowitz|
|Private MDs||Affiliated with Universities, NGOs.||MDs. RNs. Technicians.||Various.||Local, on-site.||2 days–6 months||Varies.||Varies.||Frequently sponsored by training institution.||Some.||See references.||Adler, Harris, Harris, Rijken,|
There are several societies, federations and a website which promote ultrasound education in LMICs through hosting lectures, conferences and sponsoring fellowships for training courses. Specifically, http://www.sonoworld.com represents a free, open-access resource with over 300 theoretical and ‘how to’ lectures available online (Table 2.).
The WHO Ultrasound Manual states that candidates for sonography courses should have at least 2–3 years healthcare training and have completed 250 abdominal scans, 50 first trimester scans and 200 s and third trimester scans under supervision. According to the same source, at least 6 months of full-time training in a recognised centre is required for a physician to interpret ultrasound scans with any reliability (Group 1998). Based on our review, we state that a vast majority of people practising ultrasonography in LMICs do not meet these criteria. Most ultrasonography scans are performed by generalist and obstetric physicians and even non-medical personnel with little to no formal training in ultrasonography (Table 1). Of note, there was a marked scarcity of data available regarding echocardiography training in LMICs. Current practices in ultrasonography training, as revealed by the reviewed articles, consist largely of short workshops or intensive courses provided to local health workers, nurses and physicians (Table 2). The WHO Ultrasound Manual criteria may merit amendment, nonetheless, given the independent nature of rural practice in LMICs and the potential for technology misuse; the goal of establishing a base level of ultrasonography competence for medical practitioners remains of primary clinical importance.
The reviewed literature included information on formal radiology residency training programmes in sub-Saharan Africa (Rabinowitz & Pretorius 2005). According to this review, in all of sub-Saharan Africa, five countries, Kenya, Tanzania, Nigeria, South Africa and Ghana, have a total of 19 combined programmes. Details regarding three of these programmes were included in the reviewed literature. Details regarding resident country of origin were not included; however, it can be assumed that application to these programmes from other countries in the region is limited by financial resources and information dissemination. In the programmes described, 13–26 residents were in training in a 4-year programme. Owing to inadequate numbers and lack of incentive, it is unlikely that the trained radiologist-specialist will be available in rural areas in LMICs. This scarcity highlights the importance of adequate training programmes for generalists.
The obstacles to ultrasonography training for generalists in LMICs include the logistics of access to qualified teachers and the time required to pursue focused ultrasonography training. Travel expenses can be significant, and a relative lack of on-site training opportunities requires practitioners to be absent from their place of work for some period of time. One potential solution to this problem is replication of on-site training programmes such as the Partners in Health Program in Rwanda (Shah et al. 2008, 2009). In this programme, implementation of ultrasound diagnostics in a district hospital started with a need assessment, included provision of necessary materials and education and was followed by long-term telecommunication on the progress and difficulties encountered. Additional follow-up of this programme, including repeated follow-up skill tests, material assessment and a cost analysis, would be helpful to further define the long-term effectiveness of this type of program.
Another possible solution is capacity building through programmes such as ‘Teaching the Teachers’ (Baltarowich et al. 2009; Kawooya et al. 2010). This programme trains individuals in ultrasound at several central locations and then supports the trainees as they return to their country of origin as educators themselves. In 2003, 1000 individuals were trained at the ‘Teaching the Teachers’ headquarters at the Jefferson Ultrasound Research and Education Institute (JUREI) in Philadelphia, Pennsylvania. An additional 2500 trainees were educated globally through 55 affiliated programmes (Goldberg 2003). Participants in the programme are physicians who have experience and interest in ultrasound and who pass a qualifying examination. Trainees participate in an intensive 3-month training course, with examination before, immediately following and 6 months following completion. Examination has shown doubling of test scores following the course with good retention of knowledge at 6 months (Goldberg et al. 2001).
The efforts of private doctors and small non-governmental organisations are scarcely represented in the literature (Adler et al. 2008; Harris & Marks 2009, 2011; Rijken et al. 2009). Those cases represented show excellent outcomes with regard to local personnel capacity to assimilate new technology; however, follow-up of skill retention and technology use were not included in published literature. For instance, Rijken et al. (2009) described a programme in which local health workers were educated in obstetric ultrasound scanning in a Thai–Burmese refugee camp. These health workers underwent 6 months of training based on WHO guidelines and British Medical Ultrasound Society recommendations, with annual recertification. They were able to determine gestational age using four ultrasound measurements with accuracy of within 1 week of the expatriate training physician. In a similar study at a refugee camp in Tanzania, health workers underwent only 4 days of training and subsequently underwent case log audits for 2 years. This study presented usage data, but did not include any measures of trainee examination accuracy (Adler et al. 2008). In the field of voluntarism, establishing and maintaining professional level contact with local experts will be invaluable for the success and sustainability of healthcare delivery projects. We therefore suggest that local and regional radiology societies should play an active role in coordinating with projects implemented by private physicians and NGOs. This is also stated by Gharbi in their reflections about sonography in Africa (Gharbi & Chehida 2000), and exceptionally well modelled by Bonnard et al. (2011) in schistosomiasis diagnosis in Senegal. The Bonnard paper illustrates how a single non-radiologist learner can be trained by a licensed radiologist in 8 days to conduct ultrasonography examinations for schistosomiasis with high sensitivity and specificity.
Finally, http://www.sonoworld.com is a free, open-access, online source for electronic education materials including over 200 lectures. The site is focused on the practical education of sonographers in LMICs. It is funded by private donations and is a source of online material, but not on-site education or equipment (SonoWorld 2011). This site appears to be highly applicable and exceptionally informative; however, impact is likely limited to select users with consistent Internet access. Further research is warranted to evaluate the impact of this type of Web-based education on clinical practice in remote and rural areas.
A significant limitation of our study is the fact that not all desired information on the reported ultrasound training was provided in each article, which made comparison of the different programmes difficult. Future studies in the field of ultrasonography in LMIC are advised to include information regarding recruitment, location and duration, educational and assessment methods and programme contact information (Table 3). Especially useful would be inclusion regarding sonographer accuracy.
Table 3. Checklist of items which should be included in reports of ultrasound training programs
|Training institution||Indicate the title, qualifications and type of sponsoring of the training institution or group.|
|Eligibility criteria/recruitment||Indicate the professional degrees or previous training required for inclusion. |
Indicate the method of recruitment of trainees.
|Location||Indicate the geographical location of the programme, and whether the programme focuses on urban or rural ultrasonography.|
|Course duration||Indicate both the total number of hours spent in each type of training opportunity and the total course duration days, weeks, months, etc.|
|Education method||Indicate the education method, such as didactics vs. hands-on practice with either models or human subjects. Indicate level of supervision during practice.|
|Assessment method||Indicate whether written or practical assessments were performed, how they were scored, by whom, and with what frequency were re-assessments performed.|
|Trainee accuracy||Indicate the sensitivity and specificity of trainee ultrasound diagnostic capacity.|
|Follow-up||Indicate what follow-up training and assessment were completed.|
|Funding/cost||Indicate the cost of the programme to both the institution and the trainee, with inclusion of detailed cost itemisation where possible to allow cost-benefit analysis and replication.|
|Certificate provided||Indicate whether a certificate was provided at the end of the course and who is eligible for certification as well as in which countries the certification is recognised.|
|Programme contact information||Include programme contact information to facilitate trainee application submission and transfer of information.|
This review on the training of ultrasound LMICs is limited by the fact that only published articles, available through PubMed, are reviewed. Ultrasound experiences which are not published or published articles in languages not known to the authors were not included. Such a limitation could be significant; Akhtar et al. (2010) estimated that of all research performed on ultrasound in Pakistan, only 8% ends up being published in international journals. The search terms used are another limitation of this review. If next to the terms ‘sonography’ and ‘ultrasound’ a specific country name was used instead of ‘low income countries’ or ‘developing countries’, more specific programmes and research related to sonography in that country would likely be found. As an example, one of the authors of this paper is a practising radiologist in India (VS), he is personally aware of at least four ultrasound training programmes and one publication specific to his region which were not identified with our search terms (Gupta et al. 2010). According to the same author, these training programmes frequently have a commercial motive, not only for the trainers but also for the trainees. A basic primary care doctor in India can charge about Rs. 50 (US $1) for an outpatient visit, but if they include an ultrasound scan of the abdomen they could charge anywhere between Rs. 250–500. In addition, recent publications have highlighted the misuse and overuse as well as misdiagnosing with ultrasonography in LMIC (Chaturvedi et al. 2007; Gammeltoft & Nguyen 2007a,b; Chigbu et al. 2008; Gonzaga et al. 2010). Currently, these themes are mostly described in obstetric ultrasound, specifically with regard to the commercialisation of ultrasound and its application in circumstances where it is not clinically indicated. Further investigation of this trend is important.
Lastly, we did not discuss education regarding short- or long-term maintenance of ultrasound machines, which is a necessity when working in rural or isolated areas. This is an important aspect and should be included in sonography training.
With this review, we reflect on sonography training available in LMICs. We find that the majority of personnel practising ultrasonography have little or no formal training. A variety of programme models exist to address this deficit. We recommend that all such programmes be affiliated with a local radiologist or a local radiological association to ensure long-term follow-up. Further research and resourcing is necessary to identify and implement models appropriate to each clinical context.