The goal of this randomized controlled trial was to evaluate whether Deliberate Virtual Reality (VR) training can improve surgical skills, knowledge, and confidence in performing postpartum hysterectomy among junior-level Zambian physicians in training.

The main questions it aims to answer are:

1. Can VR-based surgical training improve technical surgical skills in a real-world setting?
2. Does Deliberate VR training enhance knowledge retention and confidence compared to standard clinical training?

Study Design: Researchers randomly assigned participants to either:

1 Deliberate VR Training (intervention group): A 9-day VR-based surgical training program 2. Standard Training (control group): Conventional clinical education

Participants underwent assessments of surgical skills, knowledge, and confidence before and after training using objective structured assessment of technical skills (OSATS) and knowledge exams.

Key Findings:

1. The Deliberate VR group demonstrated significantly greater improvements in surgical knowledge, confidence, and OSATS scores compared to the standard training group.
2. VR training showed strong skill transfer to real-world surgical performance, suggesting that affordable and scalable VR training can help bridge surgical workforce gaps in resource-constrained settings.

This study highlights VR-based training as a potential scalable solution to strengthen surgical capacity in maternal health, addressing workforce shortages and improving equitable access to essential surgical care.

This study evaluates the effectiveness of Deliberate Virtual Reality (VR) Training as an innovative educational intervention for enhancing surgical skills, knowledge retention, and confidence in postpartum hysterectomy management among junior physicians in Zambia. The study employs a randomized controlled trial (RCT) with a crossover design, ensuring that all participants ultimately experience the VR training.

Study Rationale and Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality, particularly in low-resource settings where access to highly trained surgeons is limited. Traditional surgical training models rely on mentorship and hands-on experience, which may not be feasible in under-resourced clinical environments with limited faculty. Virtual reality offers a scalable, cost-effective alternative, allowing trainees to repeatedly practice surgical techniques in a controlled environment before real-world application.

Intervention Details: The Deliberate VR training model is a 9-day self-guided, simulation-based program designed to: Provide a structured, step-by-step approach to learning postpartum hysterectomy procedures. Utilize interactive VR environments that allow real-time assessment and feedback. Offer progress tracking and individualized goal-setting for surgical skill mastery. Incorporate reflection exercises to reinforce deliberate practice techniques.

Study Procedures: Participants were randomly assigned to two groups:

1. Intervention Group: Immediate Deliberate VR Training.
2. Control Group: Standard clinical training, followed by cross-over to VR training.

Outcomes:

1. Primary outcomes include surgical proficiency (measured via OSATS scoring) and knowledge acquisition.
2. Secondary outcomes assess confidence, skill retention, and real-world application in surgical settings.

Ethical Considerations: Ethical approval was obtained from University of Zambia Biomedical Research Ethics Committee, Southern Methodist University, University of North Carolina at Chapel Hill, and King's College London. Written informed consent was obtained from all participants. The study followed the Declaration of Helsinki guidelines for ethical research involving human participants.

Potential Impact The findings from this study may inform global health education strategies by demonstrating how low-cost VR interventions can strengthen surgical training, particularly in regions with surgical workforce shortages. If successful, this model could be adapted for other critical procedures and integrated into postgraduate medical training programs in resource-constrained settings.

Inclusion Criteria:Participants were eligible for the study if they met the following criteria:

1. Junior-level Zambian physicians.
2. Recent graduates of the General Medical Officers (GMO) training program or first-year Obstetrics and Gynecology residents.
3. Within the first 18 months of their training at public hospitals in Lusaka, Zambia.
4. Actively involved in the clinical and surgical management of postpartum hemorrhage (PPH).
5. Available for the full duration of the 9-day training period.
6. Provided verbal agreement to participate after being informed about the study objectives and procedures.

Exclusion Criteria:

1. Previously completed formal postpartum hysterectomy training.
2. Had prior experience with virtual reality (VR)-based surgical training.
3. Unable to commit to the full 9-day training schedule.
4. Did not receive permission from clinical supervisors to participate.
5. Had a medical condition or visual impairment that prevented the use of VR equipment.

Individual participant data (IPD) from this study will not be shared due to small sample size and participant confidentiality. The data collected includes sensitive training performance assessments and recorded surgical evaluations, which are not designed for public release.

Evaluators assessing surgical performance using OSATS scores were blinded to group assignment to minimize bias.