Evaluation of a Community COVID-19 Vaccine Ambassador Train-the-Trainer Program.

Racially minoritized groups are more likely to experience COVID-19 vaccine hesitancy and have lower vaccination rates.  As part of a multi-phase community-engaged project, we developed a train-the-trainer program in response to a needs assessment. "Community vaccine ambassadors" were trained to address COVID-19 vaccine hesitancy. We evaluated the program's feasibility, acceptability, and impact on participant confidence for COVID-19 vaccination conversations. Of the 33 ambassadors trained, 78.8% completed the initial evaluation; nearly all reported gaining knowledge (96.8%) and reported a high confidence with discussing COVID-19 vaccines (93.5%). At two-week follow-up, all respondents reported having a COVID-19 vaccination conversation with someone in their social network, reaching an estimated 134 people. A program that trains community vaccine ambassadors to deliver accurate information about COVID-19 vaccines may be an effective strategy for addressing vaccine hesitancy in racially minoritized communities.

Barriers and Facilitators to Prevention and Care of COVID-19 Infection in Cincinnati Latinx Families: a Community-Based Convergent Mixed Methods Study.

BACKGROUND: Latinx populations have experienced disproportionately high case rates of COVID-19 across the USA. Latinx communities in non-traditional migration areas may experience greater baseline day-to-day challenges such as a lack of resources for immigrants and insufficient language services. These challenges may be exacerbated by the COVID-19 pandemic. OBJECTIVE: This article describes the results of an initial community health needs assessment to better understand the prevention and care of COVID-19 infection in the Cincinnati Latinx community. METHODS: We used convergent mixed methods to examine barriers and facilitators to COVID-19 prevention and care for those with infection. RESULTS: Latinx adults ≥ 18 years old completed 255 quantitative surveys and 17 qualitative interviews. Overarching mixed methods domains included knowledge, prevention, work, challenges, and treatment. Quantitative results largely reinforced qualitative results (confirmation). Certain quantitative and qualitative results, however, diverged and expanded insights related to caring for COVID-19 infection among Latinx adults (expansion). There were infrequent contradictions between quantitative and qualitative findings (discordance). Primary barriers for the Latinx community during the COVID-19 pandemic included insecurities in food, jobs, housing, and immigration. Key facilitators included having trusted messengers of health-related information. CONCLUSION: Public health interventions should be centered on community partnerships and the use of trusted messengers. Wraparound services (including resources for immigrants) are essential public health services. Close partnership with employers is essential as lack of sick leave and mask supplies were more frequent barriers than knowledge. These findings emerged from experiences during the COVID-19 pandemic but likely generalize to future public health crises.

The Immigrant Partnership and Advocacy Curricular Kit: A Comprehensive Train-the-Trainer Curriculum in Immigrant and Refugee Health.

The number of immigrants and refugees in the United States is growing, yet many trainees and clinicians feel unprepared to manage the diverse needs of this population. This perspective piece describes the development of the Immigrant Partnership and Advocacy Curricular Kit (I-PACK) by the Midwest Consortium of Global Child Health Educators. I-PACK is an adjunct to the Consortium's sugarprep.org global health curricular materials. Using Kern's six-step approach to curriculum development, they developed eight modules in immigrant and refugee health that incorporate interactive learning activities. The I-PACK was launched as an open-access resource in September 2020. As of September 2021, the curriculum has been freely available at sugarprep.org/i-pack and downloaded from educators in 15 countries. The I-PACK curriculum can address a growing need in medical education to empower learners and clinicians to provide competent and compassionate care for immigrants and refugees.

Using Reflective Writing to Explore Resident Resilience during Global Health Electives.

Pediatric residents participating in global health electives (GHEs) report an improved knowledge of medicine and health disparities. However, GHEs may pose challenges that include cost, personal safety, or individual mental health issues. The objective of this study was to describe the use of guided reflections to understand resident resilience during GHEs. Forty-five residents enrolled in two pediatric training programs were asked to respond in writing to weekly prompts during a GHE and to complete a post-trip essay. Analysis of the reflections and essays, including an inductive thematic analysis, was completed. Two coders performed a second analysis to support classification of themes within the Flinders Student Resilience (FSR) framework. Four themes emerged from the initial analysis: 1) benefits, 2) stresses and challenges, 3) career development, and 4) high-value care. Analysis using the FSR framework revealed the following themes: acknowledgment of personal limitations, importance of relationships in coping throughout the GHE, and discernment of career focus. Reflective writing provided insight into how residents mitigate GHE challenges and develop resilience. Despite statements of initial distress, residents focused on their personal benefits and growth during the GHE. The FSR framework revealed the residents' robust self-awareness of limitations and that strong relationships on the ground and at home were associated with perceived benefits and growth. Programs should consider helping residents to identify healthy coping practices that can promote personal resilience during GHEs as part of pre-departure preparation and debriefing, as well as providing for supportive communities during the GHE.

Global Health Crisis, Global Health Response: How Global Health Experiences Prepared North American Physicians for the COVID-19 Pandemic.

The COVID-19 pandemic plunged hospital systems into resource-deprived conditions unprecedented since the 1918 flu pandemic. It brought forward concerns around ethical management of scarcity, racism and distributive justice, cross-disciplinary collaboration, provider wellness, and other difficult themes. We, a group of medical educators and global health educators and clinicians, use the education literature to argue that experience gained through global health activities has greatly contributed to the effectiveness of the COVID-19 pandemic response in North American institutions. Support for global health educational activities is a valuable component of medical training, as they build skills and perspectives that are critical to responding to a pandemic or other health system cataclysm. We frame our argument as consideration of three questions that required rapid, effective responses in our home institutions during the pandemic: How can our health system function with new limitations on essential resources? How do we work at high intensity and volume, on a new disease, within new and evolving systems, while still providing high-quality, patient-centered care? And, how do we help personnel manage an unprecedented level of morbidity and mortality, disproportionately affecting the poor and marginalized, including moral difficulties of perceived care rationing?

Pediatric Hospital Medicine and Global Health: A Fitting Niche for an Emerging Subspecialty.

As North American hospitals serve increasingly diverse patient populations, including recent immigrants, refugees, and returned travelers, all pediatric hospitalists (PHs) require foundational competency in global health, and a subset of PHs are carving out niches focused in global health. Pediatric hospitalists are uniquely positioned to collaborate with low- and middle-income country clinicians and child health advocates to improve the health of hospitalized children worldwide. Using the 2018 WHO standards for improving the quality of care for children and adolescents worldwide, we describe how PHs' skills align closely with what the WHO and others have identified as essential elements to bring high-quality, sustainable care to children in low- and middle-income countries. Furthermore, North American global health hospitalists bring home expertise that reciprocally benefits their home institutions.

Disinfection of Neonatal Resuscitation Equipment in Low-Resource Settings: The Importance, the Reality, and Considerations for the Future.

Preventable neonatal deaths due to prematurity, perinatal events, and infections are the leading causes of under-five mortality. The vast majority of these deaths are in resource-limited areas. Deaths due to infection have been associated with lack of access to clean water, overcrowded nurseries, and improper disinfection (reprocessing) of equipment, including vital resuscitation equipment. Reprocessing has recently come to heightened attention, with the COVID-19 pandemic bringing this issue to the forefront across all economic levels; however, it is particularly challenging in low-resource settings. In 2015, Eslami et al. published a letter to the editor in Resuscitation, highlighting concerns about the disinfection of equipment being used to resuscitate newborns in Kenya. To address the issue of improper disinfection, the global health nongovernment organization PATH gathered a group of experts and, due to lack of best-practice evidence, published guidelines with recommendations for reprocessing of neonatal resuscitation equipment in low-resource areas. The guidelines follow the gold-standard principle of high-level disinfection; however, there is ongoing concern that the complexity of the guideline would make feasibility and sustainability difficult in the settings for which it was designed. Observations from hospitals in Kenya and Malawi reinforce this concern. The purpose of this review is to discuss why proper disinfection of equipment is important, why this is challenging in low-resource settings, and suggestions for solutions to move forward.

Global Health Partnerships During the COVID-19 Pandemic: Perspectives and Insights from International Partners.

Global health partnerships (GHPs) have encountered many challenges during the coronavirus disease 2019 (COVID-19) pandemic. New perspectives and insights are needed to guide GHPs when navigating current and future collaborations. This study aimed to understand perspectives and insights of international partners regarding how the COVID-19 pandemic impacted their GHPs with institutions in the United States. We performed a cross-sectional qualitative study conducted through virtual semi-structured interviews performed between June 12, 2020 and July 22, 2020. We queried academic institutions based in the United States to refer individuals from their corresponding international GHP organizations. We invited these individuals to participate in virtual interviews that were audio-recorded and transcribed. We analyzed data qualitatively to identify themes. Eighty-four United States partners provided e-mail addresses for international partners. Ten individuals from these GHPs completed the interview. Participants reported overall positive experiences with their United States-based partners during the pandemic. The following themes emerged: imbalanced decision-making; worry about partnership continuity; opportunity to optimize communication within partnerships; interest in incorporating technology to facilitate engagement; and a desire for increased bilateral exchanges. Several challenges appeared to exist before COVID-19 and were highlighted by the pandemic. Most respondents were optimistic regarding the future of their GHPs. However, concerns were expressed regarding the implications of fewer in-person international experiences with United States trainees and the desire for stronger communication. Although our results do not represent the perspectives and insights of all GHPs, they provide considerations for the future. We urge institutions in the United States to re-examine and strive for equitable relationships with their international partners.

The Influence of Culture on Teamwork and Communication in a Simulation-Based Resuscitation Training at a Community Hospital in Honduras.

STATEMENT: Communication and teamwork are important aspects of medicine and have been a recent focus of resuscitation. Culture can influence communication and teamwork, and these effects have not been studied in low-resource settings. Using a case study and the TEAM scale, we evaluated how culture influences teamwork and communication during resuscitation simulations, in addition to examining other challenges of simulation research in low-resource settings. We observed lower scores in leadership and communication skills than have been seen in other studies using the TEAM scale, which led us to evaluate the possible role of culture in influencing these skills. The high power distance and collectivism in Latin America can make communication difficult, especially during debriefing. Furthermore, in a male-biased medical hierarchy, female nurses may be less likely to voice concerns. Ultimately, this commentary provides advice for taking the influences of culture into account when planning future simulation training in low-resource settings.

Perceived Cultural Competency Skills and Deficiencies Among Pediatric Residents and Faculty at a Large Teaching Hospital.

OBJECTIVES: To identify demographic, educational, and experiential factors associated with perceived self-efficacy in cultural competency (PSECC) for pediatric residents and faculty at a large, tertiary-care children's hospital and to identify key barriers to the delivery of culturally competent pediatric care. METHODS: We conducted a cross-sectional assessment of cultural competency (CC) education, training, and skills using an online survey of residents and faculty at a large children's hospital. With our data analysis, we sought associations between PSECC skills, cross-cultural training or work experience, and demographic background. Participants were asked to identify and rank barriers to CC care and additional training they would like to see implemented. RESULTS: A total of 114 residents (55%) and 143 faculty (65%) who responded to the survey assessing PSECC. Residents were more likely to have had CC training than faculty. More than half of the residents and faculty had participated in an underserved-group clinical experience domestically or abroad. Those residents with underserved-group experience were more likely to be comfortable with interpreter use (P = .03) and culturally sensitive issues (P = .06). Faculty who participated in underserved-group care in the United States were more likely to believe that cultural bias affects care (P = .005). Both identified time constraints, language barriers, and lack of knowledge as chief barriers to acquiring CC, and both desired more training. CONCLUSIONS: Residents and faculty at a large children's hospital believe that they lack adequate CC training. Underserved-group clinical experiences both domestically and abroad are associated with perceived improved cross-cultural care skills. Increasing the extent and quality of CC education in both resident training and faculty development is needed.

Using Simulation to Develop Care Models for Rapid Response and Code Teams at a Satellite Facility.

BACKGROUND: Our institution recently completed an expansion of an acute care inpatient unit within a satellite hospital that does not include an on-site ICU or PICU. Because of expected increases in volume and acuity, new care models for Rapid Response Teams (RRTs) and Code Blue Teams were necessary. OBJECTIVES: Using simulation-based training, our objectives were to define the optimal roles and responsibilities for team members (including ICU physicians via telemedicine), refine the staffing of RRTs and code Teams, and identify latent safety threats (LSTs) before opening the expanded inpatient unit. METHODS: The laboratory-based intervention consisted of 8 scenarios anticipated to occur at the new campus, with each simulation followed by an iterative debriefing process and a 30-minute safety talk delivered within 4-hour interprofessional sessions. In situ sessions were delivered after construction and before patients were admitted. RESULTS: A total of 175 clinicians completed a 4-hour course in 17 sessions. Over 60 clinicians participated during 2 in situ sessions before the opening of the unit. Eleven team-level knowledge deficits, 19 LSTs, and 25 system-level issues were identified, which directly informed changes and refinements in care models at the bedside and via telemedicine consultation. CONCLUSIONS: Simulation-based training can assist in developing staffing models, refining the RRT and code processes, and identify LSTs in a new pediatric acute care unit. This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.

The Call and the Challenge of Pediatric Resuscitation and Simulation Research in Low-Resource Settings.

STATEMENT: The greatest burden of younger than 5 years mortality is in low- and middle-income nations where education resources are often few. The World Health Organization recommends scale-up of simulation in these settings, but it has been poorly studied. Although there has been an increase of contextualized resuscitation simulation programs designed for these settings, sustaining clinical outcomes and provider skill retention have remained research gaps. Our team designed a study to evaluate skill retention after an initial Helping Babies Breathe training at a rural Kenya referral hospital between randomized learner groups receiving supervised mock codes with debriefing versus just-in-time training with a peer. Although we saw sustained skills retention and some clinical improvements, we were unable to answer our research question because of numerous challenges, mainly that hospital leadership preferred the implementation of 1 arm of the study over another because of lack of protected education time and resources, eliminating differences between randomized study groups. Further challenges included lack of familiarity with simulation and debriefing and lack of protected educational resources and time, cultural differences in giving feedback, undeveloped systems for documentation, and high acuity and clinical volume. Our experience teaches many important lessons in how best to implement and study simulation in low-resource settings. Best practices include long-term partnerships, flexibility, community and staff engagement, mixed methodologies including community-based participatory methods, and careful attention to educational and research capacity building.

Using quality improvement to decrease birth asphyxia rates after 'Helping Babies Breathe' training in Kenya.

AIM: The Helping Babies Breathe (HBB) programme is known to decrease neonatal mortality in low-resource settings but gaps in care still exist. This study describes the use of quality improvement to sustain gains in birth asphyxia-related mortality after HBB. METHODS: Tenwek Hospital, a rural referral hospital in Kenya, identified high rates of birth asphyxia (BA). They developed a goal to decrease the suspected hypoxic-ischaemic encephalopathy (SHIE) rate by 50% within six months after HBB. Rapid cycles of change were used to test interventions including training, retention and engagement for staff/trainees and improved data collection. Run charts followed the rate over time, and chi-square analysis was used. RESULTS: Ninety-six providers received HBB from September to November 2014. Over 4000 delivery records were reviewed. Ten months of baseline data showed a median SHIE rate of 14.7/1000 live births (LB) with wide variability. Ten months post-HBB, the SHIE rate decreased by 53% to 7.1/1000 LB (p = 0.01). SHIE rates increased after initial decline; investigation determined that half the trained midwives had been transferred. Presenting data to administration resulted in staff retention. Rates have after remained above goal with narrowing control limits. CONCLUSION: Focused quality improvement can sustain and advance gains in neonatal outcomes post-HBB training.