Development and Evaluation of the Use of Local Materials for Medical Simulation in Cancer Education in Nigeria
Authors: Jacob A. , Eguzo K. , Okwuosa C. , Ekanem U. 
Published: September 2018

Background: Lower competence and poorer training of healthcare professionals (HCP) are among the many limitations of cancer control in Nigeria. These manifest as deficiencies in advocacy, screening/diagnostic practices, and patient management. Medical simulation (MS) using models is an effective approach for sustainably improving the competence of HCP. Access to modern, silicone-based simulation models is limited in Nigeria. Cassava starch and papaya fruits are widely available in Nigeria and the tropics, but not widely used for MS. Aim: Study describes the development and evaluation of the use of locally-available materials (cassava starch and immature papaya) as MS models for Papanicolaou test and breast biopsy. Methods: Immature papaya fruits were harvested and using a sharp knife, the stalk was removed to reveal the moist cavity. The space housing the stalk was simulated as the external cervical os ( Fig 1 ). Dried cassava starch was sourced as waste from the pulp. About 100 g of starch was dissolved in a cup using cold water. Boiling water at 100°C was added to the cup and stirred into a thick gel. Gel was poured into a clear polythene bag and shaped into a broad-based dome, to simulate a breast. About 2 cm cuts of ripe plantain were embedded into the gel to simulate breast mass (Fig 2). Clinicians attending a cancer education course were trained on Papanicolaou test using the papaya model, and breast core-biopsy using the gel, respectively. Training also covered clinical breast (CBE) and pelvic examinations (PE). Pre and posttraining surveys with comments evaluating self-reported comfort levels were basis for comparison. Data analysis included descriptive statistics, Wilcoxon signed rank test, χ2 and thematic analysis. Results: Of the 92 course participants (physicians-36, nurses-16), 51 completed the course evaluation forms (response rate=55.4%; 51/92), and average number of years in practice was 8 (±5.2) years. Only 3 physicians had performed Tru-Cut biopsy previously. There was significant improvement in median self-reported comfort level for Tru-Cut (pre=2 {IQR 2-2}, post=4 {4-5}, P < 0.001). Significant improvements were also recorded for median comfort-levels on CBE (4 vs 5, P < 0.01) and PE (4 vs 5, P < 0.01). According to some participants, “it gives a visual view of organs that are not obvious. It is excellent” (#2). “it is very good semblance of a living structure; this goes to enhance hands-on practice” (#41); “simulation helps to build up confidence and improves precision prior to using actual patients” (#19); “excellent! it should be highly recommended for medical training” (#49). Conclusion: Locally-available immature papaya and cassava starch are good MS materials. Their use improved self-reported comfort levels in patient evaluation. Participants recommend widespread use of MS for continuing medical education and undergraduate training. Further studies should evaluate use of cassava starch for breast ultrasound training.[Figure: see text][Figure: see text]