Exploration of preregistration Radiography education and training models in sub-Saharan Africa: An explanatory sequential mixed-methods study.

Abstract

Introduction Radiography education across sub-Saharan Africa (SSA) varies significantly in terms of structure, regulation, and delivery. These disparities impact graduate competence, employability and workforce mobility across regions. This thesis examines the characteristics of preregistration radiography education in low-resource settings, particularly in sub-Saharan Africa. It assesses how educational inputs, regulatory frameworks and training experiences influence graduate outcomes. Methods An explanatory, sequential, multi-phase mixed-methods design was adopted, grounded in pragmatism and guided by Donabedian’s structure-process-outcome (SPO) model. Phase one consisted of a mixed-methods systematic review and document analysis of global and regional frameworks, which informed the development of a cross-sectional survey distributed across sub-Saharan Africa in phase two. The final phase involved a qualitative exploration of the Zambian radiography education landscape using an embedded single-case study design. Interviews and focus groups were used to explore stakeholder perspectives and contextualise earlier regional quantitative findings. Results In the quantitative phase, 258 responses were analysed from the 23 SSA countries. Subsequently, 22 participants from Zambia, comprising educators (n = 8), recent graduates (n = 7), and radiology service managers (n = 7), participated in follow-up interviews. Significant variations were observed in curriculum design, content, clinical exposure, and scope of practice across SSA. The study data revealed misalignment between training and workforce demands, particularly in cross-sectional imaging modalities. Clinical placements were found to be crucial for developing competence; however, their delivery was inconsistent. The single embedded case study of Zambia highlighted several barriers, including limited access to cross-sectional imaging equipment, inadequate clinical supervision, heavy reliance on informal employer-led retraining, institutional autonomy, market competition, variable onboarding processes and regulatory fragmentation. Stakeholders urged the adoption of a unified curriculum, competency-based licensure, and enhanced collaboration between academia and industry. Original contribution This study introduces the Radiography Education Systems Framework, a conceptual model that combines Donabedian’s SPO model, the Capability Approach, Experiential Learning Theory, and Policy Implementation Theory. The framework views radiography education as a layered ecosystem, covering macro-level policy and regulation, institutional curriculum design, clinical training settings, and individual graduate experiences. It emphasises how systemic misalignments at each level collectively influence graduate readiness and employability. The study introduces a novel approach to curriculum design for low-resource settings: a single-modality exit model supported by a multi-modality competence framework. This integrated framework balances the need for modality-specific expertise with the practicality of shared multi-modality training, offering an adaptable foundation for regional harmonisation and workforce mobility. Exploratory factor analysis showed that competencies in the optimal use of equipment and patient-centred image acquisition are fundamental to diagnostic radiography. Similarly, the ability to plan and deliver safe and effective treatments is essential in radiotherapy. By refining broader modality-specific profiles, this study pinpoints the threshold competencies that strongly predict graduate readiness and competence. Furthermore, the study found that clinical placements play a critical role in proficiency in advanced imaging. While competencies in CT and ultrasound showed moderate development by graduation, many skills in MRI, nuclear medicine, and radiotherapy were acquired on the job. These findings present a scalable and adaptable educational strategy. Such a model aims to address the challenges posed by limited clinical infrastructure and human resources on graduate competence, while maintaining curriculum relevance and ensuring graduate preparedness. It provides sustainable, context-appropriate solutions to meet workforce demands without overloading the education system, a vital priority in SSA. Ultimately, this study suggests that factors beyond academic preparation influence graduate employability and outcomes. Drawing on a cross-theme synthesis, this study illustrates how systemic factors, including policy, pedagogy, practice, and personal experience, collectively impact the preparedness, employability, and professional identity of radiography graduates. These findings provide a scalable model for curriculum design, licensure policy, and workforce integration, contributing original evidence towards harmonising radiography education across SSA. Conclusion Radiography education in SSA lacks standardisation and coherence concerning graduate outcomes. This thesis provides practical, evidence-based recommendations for curriculum reform and regulatory integration to enhance graduate preparedness and promote sustainable workforce development in the region.