Scoping communication training in undergraduate children's nursing programmes: A mixed method study examining delivery methods and content.

AIM: The aim of this study was to scope communication curriculum reported as currently being delivered within undergraduate children's nursing programmes across the Republic of Ireland and the United Kingdom. BACKGROUND: Communication between a children's nurse and a child/young person influences a child/young person's healthcare experience. Despite an identified need for a comprehensive and effective communication curriculum within undergraduate nursing, there is a notable gap of understanding of the delivery and content of communication training within children's nursing curricula. DESIGN: A mixed method, online anonymous self-report survey design was adopted. METHODS: Programme Leads of undergraduate children's nursing programmes in the Republic of Ireland and the United Kingdom were asked to report on how communication training is delivered to students on undergraduate children's nursing programmes. The Checklist for Reporting of Survey Studies (CROSS) was used for the reporting of this study. RESULTS: Thirty-two programme leads completed the survey (51 % response rate). Findings show variability in the delivery and content of communication training across Higher Educational Institutions. Core communication modules featured across all nursing programmes, however, only two programme leads reported delivering standalone child-centred communication modules. Communication training was not always delivered by an educator with professional experience of children and young people in healthcare. Curriculum capacity had an impact on the delivery of communication training, with clinical practice being relied on to supplement child specific communication training. Programme leads highlighted the need for greater inclusion of child voice in shaping and delivering undergraduate children's nurse education. CONCLUSIONS: This study shows that while communication is covered as a core part of the undergraduate nursing curriculum across the Republic of Ireland and the United Kingdom, it generally lacks a focus on children and young people and is not always supported by educators with professional experience of children and young people in healthcare. More work needs to focus on equipping undergraduate children's nurses with the unique skills needed to communicate effectively with children and young people and incorporate learnings into nursing pedagogy.

The mediating role of pediatric nursing competence in the relationship between pediatric drug administration self-efficacy and medical error tendency in nursing students.

AIM: This study was conducted to determine the mediating role of pediatric nursing competence in the relationship between self-efficacy in pediatric drug administration and medical error tendency in nursing students. BACKGROUND: The self-efficacy of nursing students towards drug administration knowledge and practices is one of the determinants of achieving the goals of nursing education programs related to drug administration. DESIGN: The sample of the descriptive and correlational study consisted of a total of 303 3rd and 4th-year students taking the Pediatric Health and Diseases Nursing course at the Department of Nursing. Data were collected using the Pediatric Nursing Competency Scale (PNCS), the Medication Administration Self-Efficacy Scale in Children for Nursing Students (MASSC) and the Medical Errors Tendency Scale (METS). Pearson correlation analysis, linear regression analysis, independent groups t-test, one-way analysis of variance (ANOVA) and post hoc (Tukey, LSD) test were used to analyze the data. In addition, hierarchical regression analyses regarding the mediation effect were performed using PROCESS Model 4 developed by Hayes (2013) for SPSS. RESULTS: When the correlation levels between the total scores of MASSC, PNSC and METS were analyzed, a positive moderate correlation was found between PNSC and MASSC total scores, a positive weak correlation was found between METS and MASSC total scores and a positive weak correlation was found between METS and PNSC total scores (p<0.05). As a result of the analysis, the model was found to be significant and the total change in METS was explained by 17.3 % of the total change in METS (F=63.289;p=0.000). It was found that PNSC was a partial mediator variable between MASSC and METS. CONCLUSION: As a result of the study, it was determined that pediatric nursing competence had a partial mediating role in the relationship between pediatric drug administration self-efficacy and medical error tendency in nursing students.

Just-in-Time Video Using QR Codes: An Approach to Pediatric Trauma Nursing Education.

BACKGROUND: High acuity trauma and patients in cardiopulmonary arrest are not frequently seen in all pediatric Level I trauma centers. Yet, nurses are required to manage these patients in fast-paced, high-pressure environments. OBJECTIVE: This project aims to develop and evaluate an education program for high-risk, low-volume equipment and skills in the pediatric emergency department setting. METHODS: This is a pre- and post-quality improvement study conducted in a Northeastern United States pediatric Level I trauma center. Emergency department nurses were invited to view videos detailing high-risk, low-volume equipment use. For the convenience of access, Quick Response (QR) codes linked to the videos were placed on each piece of equipment reviewed. General self-efficacy and levels of self-efficacy in using the equipment were assessed before the intervention and again after 4 weeks from January to February 2023. RESULTS: A total of 43 pediatric emergency nurses participated in the education. The mean aggregate general self-efficacy score was 32.93. Mean scores in all areas (Level 1 rapid infuser, fluid warmer, blood administration, and securing an endotracheal tube) improved after the intervention. CONCLUSIONS: Easily accessible, brief refresher videos linked to QR codes in the pediatric emergency department can help empower nurses who need to use high-risk, low-volume equipment.

Multidisciplinary Design-Based Multimodal Virtual Reality Simulation in Nursing Education: Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic underscored the necessity for innovative educational methods in nursing. Our study takes a unique approach using a multidisciplinary simulation design, which offers a systematic and comprehensive strategy for developing virtual reality (VR) simulations in nursing education. OBJECTIVE: The aim of this study is to develop VR simulation content for a pediatric nursing module based on a multidisciplinary simulation design and to evaluate its feasibility for nursing education. METHODS: This study used a 1-group, posttest-only design. VR content for pediatric nursing practice was developed by integrating the technological characteristics of a multimodal VR system with the learning elements of traditional nursing simulation, combining various disciplines, including education, engineering, and nursing. A user test was conducted with 12 nursing graduates (preservice nurses) followed by post hoc surveys (assessing presence, VR systems, VR sickness, and simulation satisfaction) and in-depth, one-on-one interviews. RESULTS: User tests showed mean scores of 4.01 (SD 1.43) for presence, 4.91 (SD 0.81) for the VR system, 0.64 (SD 0.35) for VR sickness, and 5.00 (SD 1.00) for simulation satisfaction. In-depth interviews revealed that the main strengths of the immersive VR simulation for pediatric pneumonia nursing were effective visualization and direct experience through hands-on manipulation; the drawback was keyword-based voice interaction. To improve VR simulation quality, participants suggested increasing the number of nursing techniques and refining them in more detail. CONCLUSIONS: This VR simulation content for a pediatric nursing practice using a multidisciplinary educational design model was confirmed to have positive educational potential. Further research is needed to confirm the specific learning effects of immersive nursing content based on multidisciplinary design models.

Impact of the Nursing and Midwifery Council (2018) future nurse: Standards of proficiency for registered nurses on children's nursing curriculum - A cross-sectional study.

BACKGROUND: Student nurses in the United Kingdom undertake field-specific pre-registration education. The implementation of the Nursing and Midwifery Council (2018) Future nurse: Standards of proficiency for registered nurses, has raised concerns that the increasingly generic component of pre-registration programmes is not adequately preparing newly qualified children's nurses to care for children safely. OBJECTIVE: To investigate how the introduction of the Nursing and Midwifery Council standards in the United Kingdom has impacted the structure and field specific content of pre-registration children's nursing programmes. SETTINGS: An online survey completed by 54 programmes, field, or professional leads linked to 76 pre-registration children's nursing programmes. This represents 80 % of higher education institutions with Nursing and Midwifery Council approved pre-registration children's nursing programmes across all four United Kingdom countries. METHODS: A survey to capture the current content and changes to curricula since the introduction of the Nursing and Midwifery Council (2018) Future nurse standards. The survey included closed-ended and open-ended questions. Closed-ended questions were statistically analysed using SPSS v.28 for Windows. Open-ended questions were thematically analysed using Quircos v.2.1. RESULTS: 50 % of respondents reported changes to theoretical content. In 27 programmes (35.5 %) there was a decrease in child-specific content. Child specific teaching methods accounted for less than 30 % of the content of all programmes whereas cross-field teaching methods (Adult, Mental Health, Learning Disability and Child learners together) accounted for over 70 % of the taught content. Analysis of qualitative data identified three themes: genericism as the focus, the challenge to achieve the standards' proficiencies, and dilution of child specific content. CONCLUSIONS: The survey responses show disparities in how United Kingdom higher education institutions have interpreted the Nursing and Midwifery Council standards highlighting academics concerns on the growing genericism within pre-registration children's nurse education nationally. These findings will inform the next stage of the project comparing the impact of greater or lesser degrees of genericism on the outcomes of the programme for newly qualified children's nurses.

The effect of outcome-based education on clinical performance and perception of pediatric care of the third-year nursing students in Mongolia.

BACKGROUND: Mongolian government has set improvement of clinical proficiency of nursing students as one of its priorities. Nursing professionals have the sentinel role in providing healthcare services in rural areas. Outcome-based education (OBE) offers a promising pedagogical approach to actively mentally engage students to strengthen their clinical proficiencies. We implemented a pilot project with the objective of comparing students' clinical performance under OBE with our traditional didactic techniques. METHODS: The researchers implemented a non-equivalent two-armed quasi-experimental post-test-only' design approach study. The intervention arm (n = 34) received OBE pediatric training, while the control arm (n = 32) received the traditional pedagogical pediatric nursing training. Each arm of the study completed 16 hours of theory, 32 hours of clinical skills practice and 32 hours of seminars in pediatric nursing care. Data were collected using a five-section instrument, Demographic, Competency Inventory, Nursing Students' Satisfaction, Course Experience, and Objective Structured Clinical Examination. Performance and knowledge proficiencies were evaluated by applying the two-sided independent T-test. The distributions of categorical variables were assessed by Fisher's exact test or chi-squared test of significance. RESULTS: The intervention arm had higher mean score value in the competency inventory ([Formula: see text] = 238.70, SD = ± 23.07) compared to the control arm ([Formula: see text] = 222.11, SD = ± 39.94) (P = 0.04); similarly, the mean value for nursing students' satisfaction was higher for the intervention arm ([Formula: see text] = 117.87, SD = ± 15.94) compared to the control group ([Formula: see text] = 109.76, SD = ± 16.94) (P = 0.049). Additionally, the difference in the mean value for course experience questionnaire between the intervention arm ([Formula: see text] = 125.33, SD = ± 19.30) and the control arm ([Formula: see text] = 110.41, SD = ± 11.28) was statistically significant (P = 0.0001). Finally, the intervention arm had a higher mean value ([Formula: see text] = 85.40, SD = ± 6.11) for objective structural clinical examination compared to the control arm ([Formula: see text] = 81.56, SD = ± 7.01) (P = 0.023). CONCLUSION: OBE pedagogical approach offers promising benefits to improving nursing students' clinical competencies; additionally, the OBE approach seems to increase students' satisfactions with their clinical curriculum.

Promoting infant safe sleep practices among neonatal and paediatric nurses through simulation-based training program.

PURPOSE: To evaluate the effect of a Simulation-based training (SBT) program on neonatal and paediatric nurses' knowledge regarding infant safe sleep practices. BACKGROUND: Sudden infant death syndrome (SIDS) presents a major public health concern, preventable through the promotion of optimal safe sleep practices, particularly among neonatal and paediatric nurses. Despite its effectiveness in enhancing nurses' knowledge and clinical skills, SBT is not an adopted training method for nurses in Egypt. DESIGN AND METHODS: A single-group pre- and post-test design involved 57 nurses from Neonatal Intensive Care Unit, Paediatric Intensive Care Unit, and Paediatric In-patient Unit. The study consisted of two stages. In the first stage, knowledge assessment to identify deficiencies. The second stage, researchers developed four SBT scenarios. Two of these scenarios were recorded for training purposes, while the other two were intended for nurses to actively participate in. Data were collected from May 2022 to January 2023. RESULTS: A significant improvement in nurses' knowledge of infant safe sleep practices and SIDS prevention was observed (p = 0.000). Nurses expressed high satisfaction with the training program (mean score 45.035 ± 4.38). CONCLUSION: This study provides evidence that simulation-based training is an effective approach to promoting safe infant sleep practices among neonatal and paediatric nurses. PRACTICE IMPLICATIONS: Integrating SBT programs into nursing education can enhance nurses' knowledge and skills in infant-safe sleep practices, providing a realistic and interactive learning experience.

Implementing Strengths-Based Nursing and Healthcare: A Decade of Leadership and Learning in a Canadian Pediatric Rehabilitation Setting.

The nursing context in pediatric rehabilitation is that of caring for children with disabilities and complex developmental differences and health conditions in an ever-changing and demanding environment. Rehabilitation nurses aim to continuously advance nursing leadership, practice, education and research to meet service needs. Strengths-Based Nursing and Healthcare (SBNH) is a philosophy and value-driven approach that aligns with and enables the advancement of strengths-based rehabilitation nursing and family-centred care. This paper describes the leadership approach undertaken to implement SBNH in a Canadian pediatric rehabilitation hospital context over a 10-year period. We will share what we did and what we learned.

Integrating Strengths-Based Nursing and Healthcare in Pediatric Nursing Education: A Case Study of the Ghana-SickKids Partnership.

There is growing recognition of the critical role nursing leadership plays in healthcare. Integrating strengths-based approaches into nursing education enables positive learning settings and empowers nurses as leaders who foster healing and well-being for patients and their families. This paper describes an effort to integrate Strengths-Based Nursing and Healthcare (SBNH) and Strengths-Based Nursing and Healthcare Leadership (SBNH-L) into the development, implementation and evaluation of a postgraduate pediatric nursing program in Ghana. In the evaluation of the program in Ghana, three themes emerged related to strengths-based nursing: transformation of teaching and learning, impact on relationships with colleagues and impact on relationships with patients.

Are pediatric practicum experiences a beneficial component of registered nurse education programs? Nursing students and new graduates weigh in: A qualitative descriptive research study.

BACKGROUND: In Canada, the British Columbia College of Nurses and Midwives requires baccalaureate registered nurse education programs to deliver a generalist curriculum meeting entry-level competencies. To fulfill this requirement, nursing programs ensure the provision of practice opportunities for hands-on experience with patients of all ages through practicum. Current literature suggests the limited availability of clinical placement opportunities in pediatric settings. This may reduce the opportunity for nursing students to become acquainted with the unique needs of infants, children, and adolescents as part of their nursing education. AIM: This study aimed to explore students' and new graduates' experiences of acute and community pediatric clinical practicum as part of their British Columbia nursing education program. SETTINGS, PARTICIPANTS, AND METHODS: This study utilized a qualitative descriptive approach. Fifteen online semi-structured interviews were conducted with thirteen undergraduate nursing students and two recent graduates. Participants in this study were distributed across the province of British Columbia, representing the North, the Interior, and the Lower Mainland. Data were analyzed using thematic analysis. RESULTS: The key themes of relational practice and exposure to lived experiences (and their related subthemes) are explored in detail. Both themes encapsulate the importance that nursing students ascribe to the pediatric practicum experience as part of their nursing education. CONCLUSION: The result of this study deduced that the pediatric practicum experience provided nursing students with learning opportunities they may not get elsewhere such as: building relationships with children, adolescents, and their families within the context of care and developing awareness of the lived experiences of health and illness with each patient encounters. This unique perspective of nursing students may prove valuable for the planning and delivery of clinical learning in nursing education programs.

Effect of Educational Interventions for Improving the Nurses' Knowledge, Attitude, and Practice of Pediatric Pain Management: A Aystematic Review and Meta-Analysis.

OBJECTIVE: This study aimed to evaluate the effectiveness of educational interventions in improving nurses' knowledge, attitude, and practice regarding pediatric pain management. DESIGN: Systematic review and meta-analysis. DATA SOURCES: A comprehensive search was conducted in MEDLINE, Scopus, Cochrane database, Google Scholar, and trial registries, supplemented by bibliography searches. REVIEW/ANALYSIS METHODS: This review included randomized controlled trials, nonrandomized trials, and quasi-experimental trials with control groups. Eligible studies involved nurses (professionals or students) caring for pediatric patients and featured any form of educational intervention for pain management. Pooled effect estimates were calculated using a random effects model, and heterogeneity was assessed using the I-squared statistic. RESULTS: The pooled results demonstrated a significant improvement in nurses' knowledge and attitudes toward pediatric pain management postintervention, with a Standardized Mean Difference (SMD) of 2.41 (95% CI: 0.58-4.23). Additionally, the pooled results indicated a higher likelihood of effective pain medication administration (OR = 1.98; 95% CI: 1.21-3.27). However, there was no significant difference in the utilization of pain assessment tools (OR = 19.85; 95% CI: 0.29-1352.98). Pooled OR was 3.42 (95% CI: 1.93-6.07), showing significantly higher odds of ability to administer nonpharmacological interventions. Sensitivity analyses confirmed the robustness of these findings. CONCLUSIONS: Educational interventions significantly improve nurses' knowledge, attitudes, and ability to administer both pharmacological and nonpharmacological pediatric pain management interventions.

How does training given to pediatric nurses about artificial intelligence and robot nurses affect their opinions and attitude levels? A quasi-experimental study.

PURPOSE: This study was conducted to investigate the effect of training provided to pediatric nurses on their knowledge and attitude levels about artificial intelligence and robot nurses. DESIGN AND METHODS: In this study, a single-group pre- and post-test quasi-experimental design was used. Data were collected from pediatric nurses working in Training and Research Hospital located in western Turkey. Forty-three pediatric nurses participated in the study. The study data were collected using the "Pediatric Nurses' Descriptive Characteristics Form", "Artificial Intelligence Knowledge Form", and "Artificial Intelligence General Attitude Scale". RESULTS: The mean scores of the participating pediatric nurses obtained from the Artificial Intelligence Knowledge Form before, right after and one month after the training were 41.16 ± 14.95, 68.25 ± 13.57 and 69.06 ± 13.19, respectively. The mean scores they obtained from the Positive Attitudes towards Artificial Intelligence subscale of the Artificial Intelligence General Attitude Scale before and after the training were 3.43 ± 0.54 and 3.59 ± 0.60, respectively whereas the mean scores they obtained from its Negative Attitudes towards Artificial Intelligence subscale were 2.68 ± 0.67 and 2.77 ± 0.75, respectively. CONCLUSIONS: It was determined that the training given to the pediatric nurses about artificial intelligence and robot nurses increased the nurses' knowledge levels and their artificial intelligence attitude scores, but this increase in the artificial intelligence attitude scores was not significant. PRACTICE IMPLICATIONS: The use of artificial intelligence and robotics or advanced technology in pediatric nursing care can be fostered.

Simulation, Storytelling, and Pediatric End-of-Life Care: A Continuing Professional Development Approach for Nurse Residents.

Background: Providing end-of-life (EOL) care to pediatric patients and their families is challenging. Newly licensed nurses, especially those working with the hematology/oncology population, have little to no experience providing the specialized care needed for the dying child. An evidence-based continuing professional development activity provided a novel approach to improve the knowledge, attitudes, and comfort levels of nurse residents related to pediatric EOL care. Method: A high-fidelity simulation module of a pediatric oncology patient at the EOL was embedded into a 12-month nurse residency program. The module employed several teaching strategies including a storytelling approach. Results: Thirteen pediatric nurse residents participated in the program. While the evidence-based intervention increased participants' EOL care knowledge, their overall attitudes, and comfort levels remained unchanged. Discussion: EOL simulation with a storytelling approach is a highly valuable method of teaching new nurses how to care for a dying patient. Additional studies are needed to explore how to increase the comfort levels of new nurses in the delicate population of pediatric hematology/oncology.

The effect of serious game and problem-based learning on nursing students' knowledge and clinical decision-making skill regarding the application of transfusion medicine in pediatric nursing.

PURPOSE: Comparing the effect of serious game and problem-based learning on nursing students' knowledge and clinical decision-making skill regarding the application of transfusion medicine in pediatric nursing. DESIGN AND METHODS: In this quasi-experimental study, 76 undergraduate nursing students were enrolled through a convenience sampling method, and were allocated to one of the three groups of serious game, problem-based learning, and control through the block randomization method. Data were collected using a valid and reliable 3-part researcher-made tool, completed before and two weeks after the intervention. Statistical analysis was performed using paired t-test, analysis of covariance, and Bonferroni post hoc test. A significance level of <0.05 was considered. RESULTS: After the intervention, mean scores of both knowledge and clinical decision-making skill increased significantly in both intervention groups (p < 0.05). Mean post-test scores of both knowledge and clinical decision-making skill in the serious game group, and only clinical decision-making skill in the problem-based learning group were significantly higher than the control group (p < 0.05). However, no significant difference was observed regarding mean post-test scores of both knowledge and clinical decision-making skill between the intervention groups (p > 0.05). CONCLUSIONS: Both serious game and problem-based learning are proven to be effective in improving nursing students' knowledge and clinical decision-making skill regarding the application of transfusion medicine in pediatric nursing. PRACTICE IMPLICATIONS: Since learning now occurs beyond classrooms and the new generation of students spend most of their time in virtual places, utilizing technology-based teaching methods like serious games can benefit both educators and students by providing continuous education, saving their time and expenses, etc.

The initial experiences of junior nursing college students when communicating with children during pediatric clinical practicum: A phenomenological study.

PURPOSE: Nursing students feel stressed during pediatric clinical practicum due to limited communication encounters with hospitalized children. The purpose of this study was to describe junior nursing college students' experiences of communicating with children during pediatric clinical practicums. DESIGN AND METHODS: A qualitative phenomenological research design was used. Purposive sampling was used to recruit 18 junior nursing college students who completed their pediatric clinical practicum. Data were collected using semi-structured interviews and were analyzed using Colaizzi's seven-step method for data analysis. RESULTS: Three themes emerged from the data. (1) Difficulties in communicating during initial practicum: fear, rejection, self-doubt of communication abilities, and unfamiliarity with the application of communication techniques posed frustrations among nursing students. (2) Efforts to learn during practicum: self-empowerment, seeking a diverse support system, adjusting communication methods, and striving to establish good relationships allowed nursing students to adapt to the pediatric curriculum. (3) Effective communication at the later stages of practicum: mastering fundamental communication techniques and exercising pediatric therapeutic communication techniques allowed nursing students to feel accomplished. CONCLUSIONS: Junior nursing college students initially encountered difficulties and frustration when communicating with children during their pediatric clinical practicum. This study serves as a guide for educators of pediatric nursing to design courses on communication with hospitalized children. PRACTICE IMPLICATIONS: These findings could be used to develop foundation courses on communicating with children for first-time pediatric nursing practicum students; for example, formulating a course on therapeutic play for children that encompasses communication techniques, pediatric ward simulation, and introduction to therapeutic play.

Development and effectiveness of a metaverse reality-based family-centered handoff education program in nursing students.

PURPOSE: Effective patient handoffs are vital in pediatric populations. This study aimed to develop and identify the impact of a metaverse-based handoff program using ZEPETO on nursing students' handoff competence, handoff self-efficacy, learning realism, and satisfaction. DESIGN AND METHODS: This study used a non-randomized, pre-post nonequivalent group design to develop, implement, and verify a metaverse-based handoff simulation program in a nursing school in South Korea. We assigned 69 senior nursing students from a university to an experimental group or a control group. We developed a metaverse-based, handoff simulation program of family-centered care by building a pediatric intensive care unit (PICU) using ZEPETO. The program included an online lecture, a metaverse rounding discussion, and a metaverse-based handoff simulation of postoperative care for infants with congenital heart disease. We measured handoff competence, handoff self-efficacy, learning realism, and learning satisfaction pre- and post-program. RESULT(S): The experimental group showed significantly higher handoff self-efficacy than the control group (t = 3.17, p = 0.002). No significant differences were found in handoff competency, learning realism, or learning satisfaction between the groups. CONCLUSION(S): This study confirmed that a family-centered care-based handoff metaverse simulation program based on the experiential learning theory enhanced nursing students' handoff self-efficacy. The program equipped students to conduct safe and effective handoffs in real-world clinical settings by providing an immersive learning experience and emphasizing patient-centered communication. PRACTICAL IMPLICATIONS: Based on these results, family-centered, handoff education programs are recommended to be developed that focus on learning realism and learning satisfaction to enhance nursing students' handoff competence.

Facilitators and Barriers to Pediatric Nurse Practitioner Practice in the United States: A Systematic Review.

INTRODUCTION: The pediatric nurse practitioner (PNP) workforce was designed to improve child health equity. We aimed to systematically review the evidence on facilitators and barriers to PNP practice. METHOD: We included empirical studies on PNP practice in the United States and excluded studies with non-identifiable PNP data. We applied Joanna Briggs Institute tools to appraise studies and applied critical interpretive synthesis principles to synthesize. RESULTS: The final sample is 26 studies, mostly published before 2013 and observational. Prescriptive privileges, training program availability, organizational climate, and telehealth are facilitators. Mandated physician supervision, reduced pediatric curricula, geographically disparate training programs, and poor data infrastructure are barriers. The sample is limited by a moderate to high risk of bias. DISCUSSION: Evidence suggests modifiable factors impact PNP practice and could have important implications for child health equity. We offer a theoretical model to guide robust research studying the PNP workforce and health equity.