Mapping the diffusion of innovation in medical simulation in Pakistan: a systematic review

Introduction Simulation-based education (SBE) is increasingly recognised as a key innovation in clinical training and patient safety, particularly in low- and middle-income countries (LMICs). However, the scale and diffusion of SBE in Pakistan remain unclear. This systematic review maps the national adoption using Rogers’ Diffusion of Innovation (DOI) framework. Methods A PRISMA-guided systematic review registered in PROSPERO searched PubMed, CINAHL, PsycINFO and PakMediNet through 22 July 2025 (final search date) for English- and non-English studies reporting original SBE interventions in medical training in Pakistan. Dual independent screening, data extraction and risk-of-bias assessment were performed using validated tools. Key data (study design, professional group, modality, DOI stage, Kirkpatrick level, barriers/facilitators) were extracted and summarised descriptively. Results Seventy-three studies met the inclusion criteria across multiple specialties and simulation modalities. Most interventions were at the Persuasion (41/73, 56%) or Knowledge (19/73, 26%) stages of DOI and were delivered as short-term workshops, with outcomes primarily limited to participant satisfaction and knowledge or skills acquisition (Kirkpatrick levels 1–2). Only six studies reached the Decision stage and three reported Implementation or Confirmation (structured integration or sustained use). Reported barriers included infrastructure limitations (65%), faculty shortages and lack of funding, while facilitators included local innovation, faculty development and institutional collaboration. No studies reported patient- or system-level outcomes. Discussion SBE in Pakistan shows isolated innovation but slow diffusion, with gaps in curriculum integration and higher-level evaluation. Barriers mirror those reported across LMICs in South and Southeast Asia. Advancing scalable implementation will require national policy support, funding investment, accredited faculty development and structured evaluation. These findings provide an opportunity map to integrate SBE in medical education systematically.