Assessing implementation outcomes for launching balanced energy protein supplementation: A formative study in rural Bangladesh.

Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. We conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

We Aren't Just 'Slack'ing Off: Utilizing a Digital Tool to Connect Emerging Women Leaders in Global Health.

Background: Investing in women leaders in global health catalyzes growth and positive outcomes for individuals and their communities, yet large gender disparities persist in leadership within the field due to several barriers. The use of digital tools facilitates cross-institutional and international collaborations to allow individuals or groups to create or share information, ideas, career interests, and other forms of expression via virtual communities. Digital tools can dramatically expand access to and the quantity and quality of opportunities for networking, mentoring, and collaboration to support women in their professional development. Objectives: The objective of this paper is to document tangible examples of positive experiences, connections, or collaborations resulting from connecting with other participants in a Slack network. We aimed to evaluate this network to understand how to better build, model, and scale advantageous digital networks of women leaders in global health moving forward. Methods: Semi-structured interviews were conducted virtually with seven members of the Slack network from Africa and North America who volunteered to share their experiences. Transcripts of six of these interviews were analyzed for key points using thematic analysis to derive short vignettes from each interview. Findings: The findings of this study indicate that Slack is a highly beneficial tool for women in global health to use for facilitating job searches, mentoring opportunities, promoting project collaborations, and proposing programming and outreach ideas in a remote environment. We found distinct recommendations for utilizing this digital networking tool in a way that best supports and engages women in global health. It is important to spread awareness and ensure visibility of the network to recruit and maintain members, design the network in a way that inspires internal motivation, encourage consistent and meaningful engagement, send weekly emails, and maintain accessibility for a global membership base. Conclusions: The Slack network provides an engaging digital tool that facilitates communication, opportunities, and growth among women in global health. Digital tools such as Slack can help to increase opportunities for participants from low- and-middle-income countries to engage in the same networking and leadership opportunities as individuals from high-income countries. It remains critical to continue to build, advance, and scale advantageous networks like Slack to promote equity and accessibility among women leaders in the global north and south into the post-pandemic world.

Strategies to Improve Women's Leadership Preparation for Early Career Global Health Professionals: Suggestions from Two Working Groups.

Background: Despite advances in gender equality, women still experience inequitable gaps in global health leadership, and barriers to women's advancement as leaders in global health have been well described in the literature. In 2021, the Johns Hopkins Center for Global Health conducted two virtual working groups for emerging women leaders to share challenges and suggest solutions to advance women's leadership in global health. In this paper, we present emerging themes from the working groups, provide a framework for the results, and discuss strategies for advancing women's leadership in global health. Objectives: The objective of this paper is to synthesize and share the themes of the two working group sessions to provide strategies for improving women's leadership training and opportunities in the field of global health. Methods: Approximately 182 women in the global health field participated in two virtual working group sessions hosted by the Johns Hopkins Center for Global Health using the Zoom platform. Participants were divided into virtual breakout rooms and discussed pre-assigned topics related to women's leadership in global health. The participants then returned to share their ideas in a plenary session. Notes from the breakout rooms and transcripts from the plenary session were analyzed through a participatory and iterative thematic analysis approach. Findings: We found that the working group participants identified two overarching themes that were critical for emerging women leaders to find success in global health leadership. First, the acquisition of individual essential skills is necessary to advance in their careers. Second, the institutional environments should be setup to encourage and enable women to enter and succeed in leadership roles. The participants also shared suggestions for improving women's leadership opportunities such as including the use of virtual technologies to increase training and networking opportunities, intersectionality in mentorship and sponsorship, combatting impostor syndrome, and the importance of work-life balance. Conclusions: Investing in women and their leadership potential has the promise to improve health and wealth at the individual, institutional, and community levels. This manuscript offers lessons and proposes solutions for increasing women's leadership through improving individual level essential skills and fostering environments in which women leaders can emerge and thrive.

Assessing community engagement in Nigeria polio eradication initiative: application of the Consolidated Framework for Implementation Research.

OBJECTIVE: This study employed the Consolidated Framework for Implementation Research (CFIR) to assess factors that enhanced or impeded the implementation of community engagement strategies using the Nigerian polio programme as a point of reference. DESIGN: This study was a part of a larger descriptive cross-sectional survey. The CFIR was used to design the instrument which was administered through face-to-face and phone interviews as well as a web-based data collection platform, Qualtrics. SETTING: The study took place in at least one State from each of the six geopolitical zones in Nigeria (Nasarawa, Borno, Kano, Sokoto, Anambra, Bayelsa, Lagos, Ondo and Oyo States as well as the Federal Capital Territory). PARTICIPANTS: The respondents included programme managers, policy-makers, researchers and frontline field implementers affiliated with the Global Polio Eradication Initiative (PEI) core partner organisations, the three tiers of the government health parastatals (local, state and federal levels) and academic/research institutions. RESULTS: Data for this study were obtained from 364 respondents who reported participation in community engagement activities in Nigeria's PEI. Majority (68.4%) had less than 10 years' experience in PEI, 57.4% were involved at the local government level and 46.9% were team supervisors. Almost half (45.0%) of the participants identified the process of conducting the PEI program and social environment (56.0%) as the most important internal and external contributor to implementing community engagement activities in the community, respectively. The economic environment (35.7%) was the most frequently reported challenge among the external challenges to implementing community engagement activities. CONCLUSION: Community engagement strategies were largely affected by the factors relating to the process of conducting the polio programme, the economic environment and the social context. Therefore, community engagement implementers should focus on these key areas and channel resources to reduce obstacles to achieve community engagement goals.

Assessing Barriers to Effective Coverage of Health Services for Adolescents in Low- and Middle-Income Countries: A Scoping Review.

PURPOSE: Understanding barriers to health services, as experienced by adolescents, is important to expand effective and equitable coverage; however, there is limited discussion on methods for conducting barrier assessments and translating findings into action. METHODS: We conducted a scoping review of literature published between 2005 and 2019 on barriers to health services for adolescents in low- and middle-income countries. The review was guided by a framework that conceptualized barriers across multiple dimensions of access (availability, geographic accessibility, affordability, and acceptability), utilization, and effective coverage. RESULTS: We identified 339 studies that assessed barriers related to at least one dimension of the operational framework. Acceptability (93%) and availability (88%) of health services were the most frequently studied access dimensions; affordability (45%) and geographic access (32%) were studied less frequently. Less than half (40%) of the studies evaluated utilization, and none of the 339 studies assessed effective coverage. Attention to equity stratifiers (e.g., income, disability) was limited. Topics studied reflected only a subset of the major causes of adolescent death and disability. CONCLUSIONS: Holistic, equity-oriented approaches are needed to better understand barriers across multiple dimensions that together determine whether health services are accessible, used, and effectively meet the needs of different adolescent groups.

Prioritizing knowledge translation in low- and middle-income countries to support pandemic response and preparedness.

The COVID-19 pandemic has created urgent demand around the world for knowledge generation about a novel coronavirus, its transmission, and control, putting academic institutions at the frontline of politics. While many academic institutions are well poised to conduct research, there are well-documented barriers for these institutions, particularly in low- and middle-income countries (LMICs), to further conduct strategic synthesis and dissemination to promote knowledge utilization among policy-makers. These systemic barriers to knowledge translation (KT) pose significant challenges for academic institutions seeking to take advantage of unprecedented policy windows to inform evidence-based decision-making. Global health funding organizations should prioritize the support of academic institutions' activities along the KT pathway, including both knowledge generation and strategic dissemination, to improve knowledge uptake for decision-making to improve health. Institutional capacity-building initiatives for KT have the potential to profoundly impact responses to this and future pandemics.

Implementation of global health competencies: A scoping review on target audiences, levels, and pedagogy and assessment strategies.

BACKGROUND: As the field of global health expands, the recognition of structured training for field-based public health professionals has grown. Substantial effort has gone towards defining competency domains for public health professionals working globally. However, there is limited literature on how to implement competency-based training into learning curricula and evaluation strategies. OBJECTIVES: This scoping review seeks to collate the current status, degree of consensus, and best practices, as well as gaps and areas of divergence, related to the implementation of competencies in global health curricula. Specifically, we sought to examine (i) the target audience, (ii) the levels or milestones, and (iii) the pedagogy and assessment approaches. SOURCES OF EVIDENCE: A review of the published and grey literature was completed to identify published and grey literature sources that presented information on how to implement or support global health and public health competency-based education programs. In particular, we sought to capture any attempts to assign levels or milestones, any evaluation strategies, and the different pedagogical approaches. RESULTS: Out of 68 documents reviewed, 21 documents were included which contained data related to the implementation of competency-based training programs; of these, 18 were peer-reviewed and three were from the grey literature. Most of the sources focused on post-graduate public health students, professional trainees pursuing continuing education training, and clinical and allied health professionals working in global health. Two approaches were identified to defining skill level or milestones, namely: (i) defining levels of increasing ability or (ii) changing roles across career stages. Pedagogical approaches featured field experience, direct engagement, group work, and self-reflection. Assessment approaches included self-assessment surveys, evaluations by peers and supervisors, and mixed methods assessments. CONCLUSIONS: The implementation of global health competencies needs to respond to the needs of specific agencies or particular groups of learners. A milestones approach may aide these efforts while also support monitoring and evaluation. Further development is needed to understand how to assess competencies in a consistent and relevant manner.

Bending the Arc towards Equitable Partnerships in Global Health and Applied Training.

Background: Global health education has rapidly expanded in popularity, and many programs require applied practical experiences. Applied experiences are critical for global health training. Often a trainee from a high-income country travels to work with collaborators and partners in a low- or middle-income country. These experiences exist within partnerships between individuals and institutions that have varying objectives, including research, program implementation, or education. Attention is growing to ensure equity in these relationships in ways that are informed by the voices of collaborators and partners. Objectives: Understanding the experiences of LMIC collaborators in academic global health partnerships is essential. Our research aimed to capture views of our partners about factors impacting equitable global health partnerships. Methods: We conducted a small survey among global health collaborators and partners who host students on these experiences. Respondents were asked to rank enablers and barriers to equitable partnerships in priority order. Results were stratified by institutional affiliation and role. Results: Funding, time, engagement, and mutual opportunities for training are common enablers and barriers of global health partnerships. There were slight differences across different professional roles. Other reported factors that impact partnerships included language barriers, visa concerns, and identifying opportunities for collaboration. Conclusions: Our work highlights several barriers and enablers faced by partners that align with those reported across the global health education community. Equitable partnerships are possible and require substantial input at individual, interpersonal, and institutional levels. We reflect on two strategies to encourage partnership equity employed within our own work and discuss how these strategies can be applied more broadly.

Building Blocks of Global Health Mentorship: Motivation, Expectations, and Institutional Support.

BACKGROUND: Global health education and training experiences are in high demand. Mentorship plays an important role in successful training, but academic institutions often lack formalized mentorship support. This study aimed to evaluate perceptions of global health mentorship across disciplines at Johns Hopkins University and to understand how to better support faculty mentorship for global health training. METHODS: This is a retrospective study that used qualitative methods to assess the perceptions of students who participated in the Johns Hopkins Center for Global Health (CGH) field placement program from 2011-2013 and CGH faculty who may have served as their mentors. Qualitative data was gathered through 30 individual in-depth interviews and 4 focus groups capturing both faculty and student perspectives. Data were analyzed inductively until thematic saturation was reached; a theoretical model, which we call the "building blocks of global health mentorship" model, emerged to serve as an analytical and synthesizing framework. FINDINGS: A series of factors influenced global health mentorship from an individual to institutional level, including motivation, expectation alignment, finances, time, and knowledge. Both students and faculty reported the importance of motivation and aligned expectations to the mentorship experience and, more broadly, the overseas experience. Mentorship relationships were identified by students and faculty as either a catalyst or a hindrance to the training experience from both a personal and a professional point of view. Many faculty mentioned insufficient institutional support and financial resources, which negatively influenced their capacity to serve as mentors. CONCLUSIONS: Many factors, ranging from individual to institutional, influence mentorship for both faculty and students, which in turn influence international experiences. The underlying role of institutional support emerged as a highly salient influencing factor. Global health programs should harness the faculty and students' motivations and expectations, as well as provide better support to faculty serving as mentors.

Global Health Mentoring Toolkits: A Scoping Review Relevant for Low- and Middle-Income Country Institutions.

Capacity building in low- and middle-income country (LMIC) institutions hinges on the delivery of effective mentorship. This study presents an overview of mentorship toolkits applicable to LMIC institutions identified through a scoping review. A scoping review approach was used to 1) map the extent, range, and nature of mentorship resources and tools available and 2) to identify knowledge gaps in the current literature. To identify toolkits, we collected and analyzed data provided online that met the following criteria: written in English and from organizations and individuals involved in global health mentoring. We searched electronic databases, including PubMed, Web of Science, and Google Scholar, and Google search engine. Once toolkits were identified, we extracted the available tools and mapped them to pre-identified global health competencies. Only three of the 18 identified toolkits were developed specifically for the LMIC context. Most toolkits focused on individual mentor-mentee relationships. Most focused on the domains of communication and professional development. Fewer toolkits focused on ethics, overcoming resource limitations, and fostering institutional change. No toolkits discussed strategies for group mentoring or how to adapt existing tools to a local context. There is a paucity of mentoring resources specifically designed for LMIC settings. We identified several toolkits that focus on aspects of individual mentor-mentee relationships that could be adapted to local contexts. Future work should focus on adaptation and the development of tools to support institutional change and capacity building for mentoring.

Conceptual Framework of Mentoring in Low- and Middle-Income Countries to Advance Global Health.

Although mentoring is not a common practice in low- and middle-income countries (LMICs), there is a strong need for it. Conceptual frameworks provide the structure to design, study, and problem-solve complex phenomena. Following four workshops in South America, Asia, and Africa, and borrowing on theoretical models from higher education, this article proposes two conceptual frameworks of mentoring in LMICs. In the first model, we propose to focus the mentor-mentee relationship and interactions, and in the second, we look at mentoring activities from a mentees' perspective. Our models emphasize the importance of an ongoing dynamic between the mentor and mentee that is mutually beneficial. It also emphasizes the need for institutions to create enabling environments that encourage mentorship. We expect that these frameworks will help LMIC institutions to design new mentoring programs, clarify expectations, and analyze problems with existing mentoring programs. Our models, while being framed in the context of global health, have the potential for wider application geographically and across disciplines.

Evaluation and Support Mechanisms of an Emerging University-wide Global Health Training Program.

BACKGROUND: Global health education is in high demand in the United States, across the continuum of learning, and field experiences are an essential part of this education. However, evaluations of these programs are limited. OBJECTIVES: The aim of this study was to evaluate a field placement program at Johns Hopkins University, in Baltimore, Maryland, to understand how to better support student training overseas and faculty mentorship. METHODS: We used qualitative and quantitative methods to gather data from program reporting requirements (152 student surveys and 46 experiential narrative essays), followed by 17 semistructured interviews, and 2 focus groups. Data were analyzed through manual coding and a socioecological model served as an analytical and a synthesizing framework. FINDINGS: A series of factors influence the participants' experience in overseas placements spanning across 4 aggregate levels, from individual to societal, including opportunity for professional advancement, independence, loneliness and illness, mentorship quality, funding, institutional partnership building, opportunity for public health contribution, and for development of cultural competency. Faculty and students thought that the program was beneficial to the learning experience, particularly for its contribution to experiential knowledge of a low- and middle-income country setting and for developing cross-cultural relationships. Communication and scope of work were 2 areas in which students and faculty members often had different expectations and many students emerged having cultivated different skills than they or their mentor initially expected. Students found the experience useful for both their academic and professional careers and faculty members saw mentorship, one of their professional responsibilities, emerge. CONCLUSIONS: Many socioecological factors influence an overseas field experience, which in turn produces important effects on students' career choices, and faculty members appreciate the opportunity to serve as mentors. The most vital support mechanisms suggested for faculty and students included available funding, clear preparation, and communication facilitation across the experiential continuum.