Review

Advancing Medical Education Using Virtual and Augmented

Reality in Low- and Middle-Income Countries: A Systematic and
Critical Review
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;
[email protected] (X.L.); [email protected] (G.S.)
2 Department of Computer Science and Engineering, The American University in Cairo,
New Cairo 11835, Egypt; [email protected]
* Correspondence: [email protected]

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
Citation: Li, X.; Elnagar, D.; Song, G.; challenges such as accessibility and device limitations remain, demonstrating the need for ongoing
Ghannam, R. Advancing Medical
research and integration with traditional methods to fully leverage these technologies for effective
Education Using Virtual and
medical education. Therefore, this review provides a comprehensive analysis of existing VR and
Augmented Reality in Low- and
AR applications, their evaluation methodologies, and student perspectives to address educational
Middle-Income Countries: A
Systematic and Critical Review.
challenges and enhance healthcare outcomes in LMICs.
Virtual Worlds 2024, 3, 384–403.
https://doi.org/10.3390/ Keywords: virtual reality; augmented reality; medical education; LMICs
virtualworlds3030021

Academic Editor: Zhonghua Sun

Received: 12 June 2024 1. Introduction

Revised: 19 August 2024 Today, the world of medicine is facing many challenges, ranging from the shortages
Accepted: 26 August 2024 of health workers in Low- and Middle-Income Countries (LMICs) to the urgent need for
Published: 18 September 2024 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 prac-
Copyright: © 2024 by the authors.
tical exposure. Cadavers, for instance, have been the cornerstone of anatomy teaching
Licensee MDPI, Basel, Switzerland.
This article is an open access article
for centuries. However, not only are they expensive and ethically challenging but their
distributed under the terms and
availability is also limited [3,4]. Therefore, traditional medical teaching methods, although
conditions of the Creative Commons
time-tested, present financial, ethical, and logistical challenges that, in today’s fast-paced
Attribution (CC BY) license (https:// and ever-evolving medical landscape, often prove limiting. However, with VR and AR,
creativecommons.org/licenses/by/ medical students can practise in a computer-generated environment, which means they
4.0/). can try things many times without any real-world risks [5].

Virtual Worlds 2024, 3, 384–403. https://doi.org/10.3390/virtualworlds3030021 https://www.mdpi.com/journal/virtualworlds

Virtual Worlds 2024, 3 385

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 trans-
formative 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 uni-
formly, ensuring that learners receive standardised and consistent quality education [15,16].
Furthermore, integrating Artificial Intelligence (AI) into these virtual platforms can pro-
vide in-depth performance analytics, tailor scenarios to individual learner needs, and
make virtual patient [17,18] interactions more realistic. Combining the concepts of stan-
dardised 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, particu-
larly 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?
Virtual Worlds 2024, 3 386

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).

2. Methodology
In this section, we demonstrate the research methodology used to explore the po-
tential 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 System-
atic 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.
Virtual Worlds 2024, 3 387

Table 1. Search terms used in the systematic review.

Immersive Medical Training Resource-

Concepts
Technology Discipline Methods Limited
LMICs,
Anatomy, Low-and-
AR, Surgery, Training, middle-income
VR, Physiology, Education, areas,
Keywords
MR, Pathology, Simulation, Rural-and-
XR Pharmacology, Telementoring remote,
Biochemistry Resource-
limited

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.

Table 2. PICO framework of the systematic review.

Framework Description Inclusion Exclusion

Medical interns,
Medical staff in medical students, No resource-
Population
resource-limited areas surgeons, limited situations
nurses
Medical training
AR, VR, Non-immersive
Intervention using immersive
MR, XR technology
technology devices
Only the evaluation
No evaluation of the
The comparison of of the immersive
Comparison immersive technology
the effectiveness technology devices,
devices
comparisons
Negative or positive New XR system,
Outcome No outcome
attitudes evaluation

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
Virtual Worlds 2024, 3 388

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.

Figure 2. PRISMA flowchart [27] for systematic reviews.

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.
Virtual Worlds 2024, 3 389

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.

Figure 3. Number of research studies on applications of VR and AR for medical training in resource-
limited situations.

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.
Virtual Worlds 2024, 3 390

Table 3. Shortlisted articles included in our systematic review.

Sample Effect- Evaluation

No. Year Location XR Device Application Discipline Reference
Size Iveness Type
Medical
1 2017 Canada * AR HoloLens Non-specific 24 + Questionnaire [37]
imaging
General Skills tests,
2 2018 Zambia VR Oculus Rift Surgery 10 + [23]
surgery Observation
General
3 2018 Gaza AR N/A Surgery N/A + N/A [38]
surgery
Google General
4 2018 Mozam-bique AR Surgery 12 + Questionnaire [24]
Glass surgery
STAR General Skills tests,
5 2019 US* AR Surgery 20 + [25]
(Hololens) surgery self-assessment
General
6 2019 Zambia VR Oculus Rift Surgery 10 + Skills tests [39]
surgery
Minimally
SIMISGEST-
7 2020 Colombia VR Surgery invasive 148 + Skills tests [40]
VR
surgery ***
8 2020 Brazil VR N/A Recovery Cardiology 61 - Observation [41]
Ward
9 2021 UK * AR HoloLens 2 Non-specific 11 + Questionnaire [42]
round
Skills tests,
Nigeria,
10 2021 VR N/A Other Neonatology 274 + Knowledge [43]
Kenya
tests
General Semistructured
11 2021 Zambia VR Oculus Rift Surgery 11 + [44]
surgery interviews
Nigeria,
12 2022 VR N/A Other Neonatology 179 + Skills tests [45]
Kenya
The Laparoscopy Questionnaire,
13 2022 VR PoLaRS Surgery 38 + [26]
Netherlands * ** skills tests
Human
interper-
14 2023 UK * VR N/A sonal Urology 32 + Questionnaire [21]
be-
haviour
AR,
15 2023 USA * Zspace Anatomy Cardiology 27 + Questionnaire [22]
VR
HTC Vive Skills tests,
16 2023 Finland * VR Surgery Otolaryngology 30 + [46]
Pro self-assessment
Microsoft
17 2023 India AR Surgery Oncology N/A + N/A [47]
Hololens 2
* 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.

Figure 4. Research divided by category and usage mode of immersive technology.

Virtual Worlds 2024, 3 391

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 recognis-
ing 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 train-
ing [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.

Figure 5. Medical application of VR and AR. Image shows that “surgery” is the most common application.
Virtual Worlds 2024, 3 392

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%).

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 tech-
nologies in medical training, particularly in resource-limited settings. Between 2019 and
2021, more comprehensive studies were conducted. Studies like Bala et al. [42] demon-
strated 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
Virtual Worlds 2024, 3 393

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.

Figure 7. Evaluation methods for VR or AR in medical training.

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?)
Virtual Worlds 2024, 3 394

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.

Figure 8. Perceived benefits of VR and AR, on a scale of 1 to 5, in comparison to traditional 2D illustrations.

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.

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
Virtual Worlds 2024, 3 395

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 10. Preferred learning modality according to two different LMIC countries (Egypt and Ghana).

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.

Figure 11. Barriers and concerns about using VR and AR in medical education.

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.
Virtual Worlds 2024, 3 396

Figure 12. Suggestions on immersive technology applications in medical education.

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.
Virtual Worlds 2024, 3 397

AR/VR in surgical training: Virtual Reality has revolutionised this training by pro-
viding a controlled, risk-free environment. Continuous practice in these simulated set-
tings has shown substantial improvements in surgical skill acquisition [58]. For instance,
some previous studies indicate marked reductions in procedural errors [58] and improve-
ments 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, understand-
ing 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 [67–69]. 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, under-
stand, 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 spot-
lighted 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 impec-
cable 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 med-
ical 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
Virtual Worlds 2024, 3 398

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 train-
ing, 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 move-
ments 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 sensa-
tion 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
Virtual Worlds 2024, 3 399

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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