Pulse oximetry has been used in medical care since the 1970s; a decade later its use became standard of care in high resource settings, first in the perioperative space and subsequently for use in routine vital sign monitoring [1–3]. Numerous multilateral organisations and global public health initiatives associated with them recommend increased pulse oximetry training and use, from surgical and anaesthesia initiatives to child health and welfare programmes [4–7]. Despite this, pulse oximetry is not universally available, and the COVID-19 pandemic has further highlighted the inequitable distribution of pulse oximetry use and training, among other key health care capacity measures [8,9].
In the perioperative setting, pulse oximetry use in low-resource settings has lagged behind use in high-resource settings due, in part, to decreased oximetry availability and non-universal training initiatives for all health care workers . Studies have demonstrated a need for continued strengthening of pulse oximetry use and training given identified capacity and knowledge gaps across multiple countries and additional practice areas, including trauma, obstetrics, paediatrics and neonatology [11–16].
Pulse oximetry training initiatives have been ongoing for years, but a map of the literature describing such initiatives among health care workers in low- and middle-income countries (LMICs) has not previously been conducted. To continue making progress in strengthening health care delivery, it is important to understand what pulse oximetry training initiatives have been done, the settings in which they have been conducted, and the health care workers who have been prioritised for training. We aimed to characterise the landscape of pulse oximetry training for health care workers in LMICs prior to the COVID-19 pandemic as described in the literature. To do this, we aim to address the following evaluation questions as part of our scoping review: 1) who (i.e. what type of health care workers) are being trained to use pulse oximetry in LMICs?; 2) what resources are used and how is training structured?; 3) when have they been trained?; 4) where are they being trained?; 5) why are they being trained (i.e. for what application of pulse oximetry)?; 6) how effective has the training been?
We developed a protocol a priori using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P). Given the aim to map literature related to pulse oximetry training among health care workers in LMICs prior to the COVID-19 pandemic, a scoping review was deemed the most appropriate methodology . This scoping review is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist presented in Table S1 in the Online Supplementary Document .
Search strategy and sources of evidence
We systematically searched 6 databases (PubMed, Embase, CINAHL, Cochrane Library, Scopus, and World Health Organization (WHO) Global Index Medicus) to identify studies reporting pulse oximetry training among health care workers, broadly defined, in LMICs prior to the COVID-19 pandemic. Search terms and MeSH headings related to pulse oximetry, LMIC countries, and education initiatives were developed in PubMed and adapted for other databases in collaboration with a specialist librarian presented in Table S2 in the Online Supplementary Document. We searched databases from their inception to 14 May 2021 and made no language exclusions. No exclusions were made based on study design and letters to the editor and editorials were also assessed for inclusion criteria if they were identified in the database searches. References of identified studies and relevant reviews and editorials were also reviewed. We attempted to locate full texts of studies for relevant conference abstracts and study protocols through hand searching. If no full study could be identified, protocols were excluded and abstracts were included if there was enough information for data charting; otherwise, they were also excluded.
Assessment of eligibility
We imported all references to Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org), where duplicates were removed. Two reviewers (MEP and SD or DRRB) independently assessed titles and abstracts and relevant full texts for eligibility. Studies were eligible if they 1) described training health care workers from an LMIC as defined by The World Bank in calendar year 2020 , 2) described educational interventions surrounding the use of pulse oximeters and 3) the educational initiative occurred prior to 2020. Of note, pulse oximetry did not need to be the primary focus of the educational initiative. Studies were excluded if they 1) did not conduct pulse oximetry training in an LMIC, 2) only described the introduction of pulse oximeters without mention of any training received, such as capacity or knowledge assessments without an education or training component, or 3) pulse oximetry training was not conducted for health care workers.
Data were charted using forms created in Covidence by one author (MEP, DRRB, JA or SA) and reviewed for accuracy by a second (MEP, DRRB, JA or SA), with a singular author (MEP) completing one of these steps for all included studies. Discrepancies were discussed between the two authors and a final decision made. Items charted from each study included: 1) training setting, 2) year of training, 3) population being trained, 4) reason for training, 5) training structure (pulse oximetry training materials used and length of training, when reported) and 6) pulse oximetry specific outcomes of training, when reported. If pulse oximetry specific outcomes were not reported, an alternative relevant study outcome was charted. We synthesised the results using a narrative synthesis.
A total of 7423 studies were identified and 182 screened in full. Of these, 66 met our inclusion criteria (Figure 1). A total of 55 training initiatives were identified in 42 countries, with some included studies reporting on different aspects of the same training initiative. Five overarching reasons for conducting pulse oximetry training were identified: 1) anaesthesia and perioperative care, 2) respiratory support programme expansion, 3) perinatal assessment and monitoring, 4) assessment and monitoring of children and 5) assessment and monitoring of adults.
Figure 1. PRISMA flow diagram.
Training initiatives utilised a variety of structures, teaching styles and methods of assessment. They ranged from solely focused on pulse oximetry to being broader in their focus with pulse oximetry training being a small component of the overall educational agenda. Similarly, training ranged from a brief one-hour lecture to multiday workshops with practical skills assessments participants were required to pass. Some initiatives were longitudinal in nature and followed up with trainees overtime to assess continued pulse oximetry competency and use, while others studies’ only touchpoint with trainees was at the time of the initial training session. Such differences are further described in detail below in each respective section and results table.
Anaesthesia and perioperative care
Twenty-four studies described conducting pulse oximetry training focused on perioperative teams in 21 countries globally, including 15 in the African Region, one in the European Region, three in the South-East Asia Region, and two in the Western Pacific Region (Table 1). Of these, nine had low-Income designation, nine lower-middle income and three upper-middle income. The primary foci of these efforts involved anaesthesia capacity-building and establishing the use of the World Health Organization Surgical Safety Checklist (WHO SSC). Training focused on anaesthesia providers, surgeons and nurses. Although training structure, length, and evaluation methods differed, many studies reported an increased use of pulse oximetry after training. Often, pulse oximetry capabilities were limited by availability of pulse oximeters and, secondarily, staff trained in its use. Multiple studies report increased intraoperative monitoring as well as the establishment of postoperative monitoring capabilities after training and pulse oximetry provision.
Table 1. Studies describing pulse oximetry training initiatives: Anaesthesia and perioperative care*
LMIC – lower middle-income country, UMIC – upper middle-income country, SSC – World Health Organization’s (WHO) Safe Surgical Checklist, d – days, mo – months, LIC – low-income country, HDU – high dependency unit, PACU – post-anaesthesia care unit, y – year, MCQ – multiple choice question
*Stratified by WHO Regions.
Respiratory support programme expansion
Fourteen studies in six countries representing the African Region (n = 4), South-East Asia Region (n = 1), and Western Pacific Region (n = 1) described pulse oximetry training prior to oxygen programme implementation, improved oxygen use, or expansion of bubble continuous positive airway pressure (bCPAP) or ventilatory support programmes (Table 2). One country was low-income and five were lower-middle income. Training was focused on doctors and nurses and ranged from 45-minute lectures to 3-day workshops. Studies found increased use of ventilatory and bCPAP support after training and increased use of pulse oximetry monitoring in children with pneumonia on oxygen support. One study found decreased mortality after pulse oximetry monitoring training and oxygen introduction [55–57].
Table 2. Studies describing pulse oximetry training initiatives: Respiratory support programme expansion*
LIC – low-income country, d – days, LMIC – lower middle-income country, bCPAP – bubble continuous positive airway pressure, h – hours, WHO – World Health Organization, mo – months, min – minutes, MCQ – multiple choice question
*Stratified by WHO Regions.
Perinatal assessment and monitoring
Eight studies representing 16 countries focused on pulse oximetry training of health care workers in the perinatal period, 12 of which were in the Region of the Americas and one representing the African, Eastern Mediterranean, South-East Asia, and Western Pacific Regions (Table 3). Five countries were lower-middle income and 11 were upper-middle income. One study focused on perinatal monitoring of mothers, one focused on maternal and neonatal assessment and six focused on neonatal assessment and monitoring. Among those focusing on neonates, training aimed to instruct health care workers in the use of pulse oximetry to decrease the burden of retinopathy of prematurity (ROP) and as a screening tool for critical congenital heart disease (CCHD), sepsis and pneumonia. Educational efforts most often involved neonatal nurses, obstetricians and neonatologists, although one study included community health workers and another traditional birth attendants [60,64]. Commonly cited limitations in expanding oximetry included the lack of pulse oximeters, lack of trained staff, or limited staff availability. Reported study outcomes varied but many reported increased pulse oximetry knowledge or improved neonatal screening rates after training.
Table 3. Studies describing pulse oximetry training initiatives: perinatal assessment and monitoring*
LMIC – lower middle-income country, UMIC – upper middle-income country, CCHD – critical congenital heart defects, SIBEN – Ibero American Society of Neonatology, NICU – neonatal intensive care unit, ROP – retinopathy of prematurity, m – months, d – days, MCQ – multiple choice question
*Stratified by WHO Regions.
Paediatric assessment and monitoring
Seven studies from four countries in the African Region, three of which were low-income countries and one was lower-middle income, focused on training health care workers caring for non-neonatal paediatric populations, especially those responsible for assessing children for pneumonia (Table 4). Most studies focused on training community health workers and nurses to regularly and routinely conduct vital signs assessments that included measurement of oxygen saturation. Training ranged from one-hour pulse oximetry training supplemented with additional clinical management training to a four-day emergency triaging workshop. After training, studies found increased rates of oxygen saturation measurements with several studies reporting improved morbidity and mortality among the studied population.
Table 4. Studies describing pulse oximetry training initiatives: paediatric assessment and monitoring*
LMIC – lower middle-income country, LIC – low-income country, d – days, iCCM/IMNCI – integrated community case management/integrated management of newborn and childhood illnesses, mo – months, PEWS – paediatric early warning score, IMCI – integrated management of childhood illness, h – hours, WHO – World Health Organization
*Stratified by WHO Regions.
Adult assessment and monitoring
Ten studies were conducted in six countries globally, representing the Region of the Americas (n = 3), African Region (n = 2) and the Eastern Mediterranean Region (n = 1) (Table 5). One country was low-income, three were lower-middle income and two were upper-middle income. Studies focus on training health care workers in the assessment and monitoring of adults. Six of these studies primarily focused on improving patient monitoring and the early identification of complications by increasing the frequency of vital signs measurement. As such, these studies primarily focused their training on nurses. Three studies focused on improving trauma and emergency services in LMICs. In these studies, pulse oximetry training was not the primary focus but was included as part of comprehensive training programmes that included vital sign assessments and monitoring. Training often focused on non-physician health care workers who either triage emergency and trauma patients or provide bedside care. One study focused on training primary care providers to use pulse oximetry as an adjunct in pulmonary disease management. Training ranged from 30-minute lectures to a 7-day long workshop. Pulse oximetry use and vital sign monitoring increased after these sessions, but studies reported that additional improvements could still be made, such as further increasing oximetry use and vital sign monitoring, as well as reacting to abnormal oximetry values.
Table 5. Studies describing pulse oximetry training initiatives: adult assessment and monitoring
LMIC – lower middle-income country, UMIC – upper middle-income country, h – hours, WHO – World Health Organization, min – minutes, d – days, MEWS – modified early warning score, SBAR – situation, background, assessment, recommendation, LIC – low-income country.
*Stratified by WHO Regions.
Pulse oximetry education initiatives among health care workers in LMICs focused primarily on monitoring and evaluation of patients during times of potential deterioration – such as during the perioperative period or respiratory compromise – or as a means of routine assessment or screening – such as during vital signs measurement. Training and educational programmes varied in their purpose with respect to the types of patients being targeted, the types of providers being instructed, and the depth of pulse oximetry-specific training. These initiatives included training anaesthetists or perioperative care staff, ensuring appropriate and adequate oxygen use, pulse oximetry screening for congenital diseases and infectious diseases and improving vital signs assessment for patients of all ages. Most studies focused on training doctors and nurses working in hospitals, with fewer focused on pre-hospital and community-based health care workers. Identified studies reported heterogeneous training structures for pulse oximetry, even among studies with the same goals of teaching pulse oximetry use. As such, no determination could be made about if a certain training style or method was more, or less, effective compared to another style. While these findings do not encompass all possible reasons pulse oximetry training could be conducted, they provide an overview of the training landscape as described in the literature prior to the COVID-19 pandemic.
Prior studies demonstrate that availability and use of pulse oximetry does not guarantee a proper understanding of oximetry practices, interpretation, or indications for intervention [15,83,84]. Additionally, pulse oximetry may not have been covered in primary qualification training for some health care workers . Finally, knowledge without access cannot lead to improvements in patient care, just as access without proper understanding also does not lead to improvements in care. Thus, it is important for educational initiatives to occur in tandem with provision of devices, as one is not successful without the other.
In addition to addressing improved pulse oximetry availability and education, other barriers to its use also need to be assessed. Such barriers will vary based on context-specific concerns. An appropriate, thorough, and regionally specific understanding of why pulse oximetry is not utilised in particular areas where it may be beneficial should be explored, including cost, staffing shortages and power outages. This should be enabled by engagement with local health care workers to address the most relevant and pressing concerns. Future research focusing on these issues would be beneficial to inform pulse oximetry implementation and policy reforms, with a focus on local health care workers’ needs, workflows, and behaviours. Furthermore, implementation science approaches and methodologies would help standardise the way impact of such initiatives is assessed.
Globally, the COVID-19 pandemic demonstrated the need for widespread pulse oximetry availability and training for early detection of hypoxemia . It laid bare the inequitable distribution of pulse oximeters and the need for increased access to pulse oximeters and health provider training in LMICs. Thousands of pulse oximeters have been distributed in LMICs throughout the pandemic by multilateral organisations and non-governmental organisations (NGOs), such as UNICEF and Lifebox [86,87]. The required rapid up scaling of pulse oximetry training and the increased availability of devices highlight a health systems area in need of strengthening. It showed that while pulse oximetry training has been conducted for many years across settings described in this review, it could benefit from additional investment. Improvements achieved since the start of the pandemic represent a momentary success, but for sustainability, widespread pulse oximetry introduction and appropriate training will need to continue .
This scoping review is not without limitations. This review focused on data gathered from the published literature, which we acknowledge fails to capture non-published pulse oximetry education initiatives. There may be a publication bias as to which initiatives are published and which are not. Additionally, if within a particular setting pulse oximetry is widely available and is a standard topic covered in health care schooling, educational efforts may be less likely published given its ubiquitous nature. Limitations notwithstanding, we believe this review will be beneficial to researchers, educators, and policy makers to provide a baseline understanding of many pulse oximetry education foci in LMICs prior to the COVID-19 pandemic.
Pulse oximetry training initiatives have been ongoing for decades for a variety of purposes, utilising a multitude of approaches to equip various health care workers with tools to improve patient care. It is important that these initiatives continue as pulse oximetry availability and knowledge gaps remain. Neither pulse oximetry provision nor training alone is enough to bolster patient care, but sustainable solutions for both must be considered in order to meet the needs of both health care workers and patients.
We would like to thank the specialist librarians who assisted with drafting our database search strategy.