Learning to Lead: An Exploration of Leadership Development in Obstetrics and Gynaecology.

Despite the demonstrated value of leadership in medicine, there is limited research on how physicians develop leadership skills. We administered a national survey (225 respondents) and conducted eight interviews of residents, fellows, and staff physicians in obstetrics and gynaecology to explore leadership skill development. Most (87%) positively rated the effectiveness of their leadership skills; however, the majority (98%) stated they would benefit from further training. Interview themes indicated that leadership skills can be taught, leadership training and roles should be intentional, training should be longitudinal, and barriers to training can be overcome with changes to the current model.

Sunny-Day Flooding and Mortality Risk in Coastal Florida.

Sea-level rise is likely to worsen the impacts of hurricanes, storm surges, and tidal flooding on coastal access to basic services. We investigate the historical impact of tidal flooding on mortality rates of the elderly population in coastal Florida using administrative records of individual deaths, demographics, and residential location combined with tidal gauge and high-resolution elevation data. We incorporate data capturing storm and precipitation events into our empirical model to distinguish between disruptions from routine sunny-day flooding and less predictable tropical storm-induced flooding. We find that a 1-standard-deviation (20-millimeter) increase in tidal flooding depth increases mortality rates by 0.46% to 0.60% among those aged 65 or older. Our estimates suggest that future sea-level rises may contribute to an additional 130 elderly deaths per year in Florida relative to 2019, all else being equal. The enhanced risk is concentrated among residents living more than nine minutes away from the nearest hospital. Results suggest that tidal flooding may augment elderly mortality risk by delaying urgent medical care.

The Gendered Consequences of COVID-19 for Internal Migration.

Scant evidence exists to identify the effects of the pandemic on migrant women and the unique barriers on employment they endure. We merge longitudinal data from mobile phone surveys with subnational data on COVID cases to examine whether women were left more immobile and vulnerable to health risks, relative to men, during the pandemic in Kenya and Nigeria. Each survey interviewed approximately 2000 men and women over three rounds (November 2020-January 2021, March-April 2021, November 2021-January 2022). Linear regression analysis reveals internal migrants are no more vulnerable to knowing someone in their network with COVID. Rather, rural migrant women in Kenya and Nigeria were less vulnerable to transmission through their network, perhaps related to the possible wealth accumulation from migration or acquired knowledge of averting health risks from previous destinations. Per capita exposure to COVID cases hinders the inter-regional migration of women in both countries. Exposure to an additional COVID case per 10,000 people resulted in a decline in women's interregional migration by 6 and 2 percentage points in Kenya and Nigeria, respectively.

Do referrals improve the representation of women in mobile phone surveys?

Random digit dial surveys with mobile phones risk under-representation of women. To address this, we compare the characteristics of women recruited directly with those of women recruited through referrals from male household members. The referral process improves representation of vulnerable groups, such as young women, the asset poor, and those living in areas with low connectivity. Among mobile phone users, we show a referral (rather than a direct dial) protocol includes more nationally representative proportions of women with these attributes. While seeking intra-household referrals may improve representation, we show that it does so at a higher cost.

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology.

OBJECTIVE: To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates. TARGET POPULATION: Providers working to improve health care for Canadian women and their families; patients and their families. OUTCOMES: Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition. BENEFITS, HARMS, AND COSTS: This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time. EVIDENCE: Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

Unmasking the truth: Experimental evidence of facemask compliance in Bangladesh, Kenya, and Nigeria during the COVID-19 pandemic.

High levels of compliance with public health measures are critical to ensure a successful response to the COVID-19 pandemic and other public health emergencies. However, most data on compliance are self-reported and the tendency to overreport due to social desirability could yield biased estimates of actual compliance. A list experiment is a widely used method to estimate social desirability bias in self-reported estimates of sensitive behaviours. We estimate rates of compliance with facemask mandates in Kenya, Nigeria, and Bangladesh using data from phone surveys conducted in March-April 2021. Data on compliance were collected from two different survey modules: a self-reported compliance module (stated) and a list experiment (elicited). We find large gaps between stated and elicited rates of facemask wearing for different groups depending on specific country contexts and high levels of overreporting of facemask compliance in self-reported surveys: there was an almost 40 percentage point gap in Kenya, 30 percentage points in Nigeria, and 20 percentage points in Bangladesh. We also observe differences in rates of self-reported facemask wearing among key groups but not using the elicited responses from the list experiment, which suggest that social desirability bias may vary by demographics. Data collected from self-reported surveys may not be reliable to monitor ongoing compliance with public health measures. Moreover, elicited compliance rates indicate levels of mask wearing are likely much lower than those estimated using self-reported data.

Implementation of Entrustable Professional Activities assessments in a Canadian obstetrics and gynecology residency program: a mixed methods study.

Background: Since the implementation of competency-based medical education (CBME) across residency training programs in Canada, there has been limited research understanding how entrustable professional activity (EPA) assessments are used by faculty supervisors and residents. Objective: This study examines how EPA assessments are used in an Obstetrics and Gynecology residency program and the impact of implementation on both groups. Methods: A mixed methods study design was used. Part one involved the aggregation of descriptive data of EPA assessment completion for postgraduate year 1 and 2 residents from July 2019 to May 2020. Part two involved a thematic analysis of semi-structured interviews of residents and faculty. Results: There was significant uptake of EPA assessments across community and teaching hospitals with widespread contribution of assessment data from faculty. However, both residents and faculty reported that the intended design of EPA assessments as low-stakes assessments to provide formative feedback is not how EPA assessments are experienced. Residents and faculty noted the increased level of administrative burden and related perceived stress amongst the resident group. Conclusions: The implementation of EPA assessments is feasible across a variety of sites. However, previous measurement challenges remain. Neither residents nor faculty perceive the value of EPAs to improve feedback, despite their intended nature.

Contexte: Depuis l'implantation de l'éducation médicale fondée sur les compétences (EMFC) dans les programmes de résidence au Canada, peu de recherches ont été menées pour comprendre comment les évaluations des activités professionnelles confiables (APC) sont utilisées par les superviseurs et les résidents. Objectif: Cette étude examine l'utilisation des évaluations des APC dans un programme de résidence en obstétrique et gynécologie et les impacts de son implantation sur ces deux groupes. Méthodes: La première partie de cette étude à méthode mixte a consisté en l'agrégation des données descriptives sur les évaluations d'APC pour les résidents de première et deuxième année effectuées entre juillet 2019 et mai 2020. Dans un second temps, nous avons analysé thématiquement les entrevues semi-structurées de résidents et de membres du corps professoral. Résultats: Il y a eu une importante participation aux évaluations des APC dans les hôpitaux communautaires et universitaires, avec une contribution considérable de données d'évaluation de la part des professeurs. Toutefois, alors que les évaluations des APC sont considérées à faibles enjeux etvisent à fournir une rétroaction formative, ce n'est pas de cette façon qu'elles sont vécues Les résidents et le corps professoral ont tous les deux rapporté une augmentation de la charge administrative et du niveau de stress perçu chez les résidents. Conclusion: L'implantation des APC est réaliste dans plusieurs sites. Malgré l'intention qui a motivé la mise en place des APC, ni les résidents ni le corps professoral ne perçoivent leur valeur comme moyen d'améliorer la rétroaction.

Rapid Cycle Deliberate Practice Versus Traditional Simulation to Improve Resident Performance in Forceps Deliveries.

This study aimed to assess the effectiveness of rapid cycle deliberate practice (RCDP) in improving obstetrics and gynaecology residents' performance and skill retention in forceps-assisted vaginal deliveries. Thirty-three residents were randomly assigned to RCDP or traditional debriefing. Performance was evaluated using an objective structured assessment of technical skills (OSATS) tool. There were no significant differences in immediate performance scores between groups (P = 0.082). At 4-6 months, both groups demonstrated improved performance scores (traditional, P = 0.001; RCDP, P = 0.001). Seventy-six percent of residents in the RCDP group indicated "real-time" feedback was advantageous. Three residents suggested this method was less beneficial at a senior level.

Food insecurity and COVID-19 risk in low- and middle-income countries.

The COVID-19 pandemic prompted social distancing, workplace closures, and restrictions on mobility and trade that had cascading effects on economic activity, food prices, and employment in low- and middle-income countries. Using longitudinal data from Bangladesh, Kenya, and Nigeria covering a period from October 2020 to April 2021, the paper assesses whether knowledge of a person infected with COVID-19 is associated with food insecurity, job loss and business closures, and coping strategies to smooth consumption. The likelihood of households to experience food insecurity at the extensive and intensive margins increased among those who knew an infected person in Bangladesh and Kenya.

Assessing population exposure to coastal flooding due to sea level rise.

The exposure of populations to sea-level rise (SLR) is a leading indicator assessing the impact of future climate change on coastal regions. SLR exposes coastal populations to a spectrum of impacts with broad spatial and temporal heterogeneity, but exposure assessments often narrowly define the spatial zone of flooding. Here we show how choice of zone results in differential exposure estimates across space and time. Further, we apply a spatio-temporal flood-modeling approach that integrates across these spatial zones to assess the annual probability of population exposure. We apply our model to the coastal United States to demonstrate a more robust assessment of population exposure to flooding from SLR in any given year. Our results suggest that more explicit decisions regarding spatial zone (and associated temporal implication) will improve adaptation planning and policies by indicating the relative chance and magnitude of coastal populations to be affected by future SLR.

Vegetation Changes Attributable to Refugees in Africa Coincide with Agricultural Deforestation.

The recent adoption of the Global Compact on Refugees formally recognizes not only the importance of supporting the nearly 26 million people who have sought asylum from conflict and persecution but also of easing the pressures on receiving areas and host countries. However, few countries may enforce the Compact out of concern over the economic or environmental repercussions of hosting refugees. We examine whether narratives of refugee-driven landscape change are empirically generalizable to continental Africa, which fosters 34% of all refugees. Estimates of the causal effects of the number of refugees-located in 493 camps distributed across 49 African countries-on vegetation from 2000 to 2016 are provided. Using a quasi-experimental design, we find refugees bear a small increase in vegetation condition while contributing to increased deforestation. Such a combination is mainly explained not by land clearance and massive biomass extraction but by agricultural expansion in refugee-hosting areas. A one percent increase in the number of refugees amplifies the transition from dominant forested areas to cropland by 1.4 percentage points. These findings suggest that changes in vegetation condition may ensue with the elevation of population-based constraints on food security.

Climate-Induced Migration and Unemployment in Middle-Income Africa.

One of the major unresolved questions in the study of vulnerability to climate change is how human migration will respond in low and middle-income countries. The present study directly addresses this lacuna by using census data on migration from 4 million individuals from three middle-income African countries over a 22-year period. We link these individuals to climate exposures in their origins and estimate climatic effects on migration using a fixed-effects regression model. We show that climate anomalies affect mobility in all three countries. Specifically, mobility declines by 19% with a 1-standard deviation increase in temperature in Botswana. Equivalent changes in precipitation cause declines in migration in Botswana (11%) and Kenya (10%), and increases in migration in Zambia (24%). The mechanisms underlying these effects appear to differ by country. Negative associations between precipitation anomalies, unemployment, and inactivity suggest migration declines may be due to an increased local demand for workers to offset production risk, while migration increases may be indicative of new opportunities in destinations. These country-specific findings highlight the contextually-specific nature of climate-migration relationships, and do not support claims that climate change is widely contributing to urbanization across Africa.

The changing climate-migration relationship in China, 1989-2011.

A persistent concern about the social consequences of climate change is that large, vulnerable populations will be involuntarily displaced. Existing evidence suggests that changes in precipitation and temperature can increase migration in particular contexts, but the potential for this relationship to evolve over time alongside processes of adaptation and development has not been widely explored. To address this issue, we link longitudinal data from 20 thousand Chinese adults from 1989-2011 to external data on climate anomalies, and use this linked dataset to explore how climatic effects on internal migration have changed over time while controlling for potential spatial and temporal confounders. We find that temperature anomalies initially displaced permanent migrants at the beginning of our study period, but that this effect had reversed by the end of the study period. A parallel analysis of income shares suggests that the explanation might lie in climate vulnerability shifting from agricultural to non-agricultural livelihood activities. Taken together with evidence from previous case studies, our results open the door to a potential future in which development and in-situ adaptation allow climate-induced migration to decline over time, even as climate change unfolds.

Temporary Migration and Climate Variation in Eastern Africa.

Africa is likely to experience warming and increased climate variability by the late 21st century. Climate extremes have been linked to adverse economic outcomes. Hence, adaptation is a key component of the United Nations Framework Convention on Climate Change agreements and development assistance. Effective climate adaptation policy requires an understanding of how temperature and rainfall variability affect migration patterns. Yet, how individuals in developing countries manage climate variation is poorly understood, especially in Africa. Combining high-resolution climate data with panel micro-data on migration, labor participation, and demographics, we employ regression analysis to assess temporary migration responses to local temperature and precipitation anomalies in four East African countries. We find that climate impacts are most pronounced in urban areas, with a standard deviation temperature increase and rainfall decrease leading to respective 10 and 12 percent declines in out-migration relative to mean values. Evidence from other labor market outcomes suggests that urban out-migration is not associated with reduced local employment opportunities. Instead, declines in urban out-migration appear to coincide with negative local climate employment impacts. These results challenge the narrative that temporary out-migration serves as a safety valve during climate extremes and that climate change will most strongly affect out-migration rates from rural areas in developing countries.

Do Social Protection Programs Foster Short-term and Long-term Migration Adaptation Strategies?

We examine how migration is influenced by temperature and precipitation variability, and the extent to which the receipt of a cash transfer affects the use of migration as an adaptation strategy. Climate data is merged with georeferenced panel data (2010-2014) on individual migration collected from the Zambian Child Grant Program (CGP) sites. We use the person-year dataset to identify the direct and heterogeneous causal effects of the CGP on mobility. Having access to cash transfers doubles the rate of male, short-distance moves during cool periods irrespective of wealth. Receipt of cash transfers (among wealthier households) during extreme heat causes an additional retention of males. Cash transfers positively spur long-distance migration under normal climate conditions in the long term. They also facilitate short-distance responses to climate, but not long-distance responses that might be demanded by future climate change.

A multiple-trainee, multiple-level, multiple-competency (multi-TLC) simulation-based approach to training obstetrical emergencies.

Competency-based education requires that programs increase the breadth of direct observation and assessment to improve resident training. To achieve these goals, the authors developed and executed a multiple-trainee, multiple-level, multiple-competency (Multi-TLC) obstetrical emergencies simulation curriculum. Depending upon their training level (PGY1-PGY5), obstetrics and gynaecology residents participated in various roles (i.e., first responder, second responder, confederates, and evaluators) within four simulation scenarios designed to provide opportunities for education, direct observation, and assessment across a number of competencies (i.e., medical expert, communicator, collaborator, leader, advocate, and scholar). The curriculum was carried out over 8 h spread evenly across 2 days (i.e., 4 h/day) and involved periods of pre-briefing, live simulation, and debriefing. An evaluation of the Multi-TLC was operationalised via a context-input-process-product model. This report presents the outcomes of that evaluation derived from quasi-experimental comparisons of the new and previous curricula across four priorities for simulation-based education identified by the Department of Obstetrics and Gynecology at McMaster University (Hamilton, ON, Canada): increasing learning opportunities, maintaining or improving resident learning, maintaining or reducing program costs, and improving resident satisfaction. The evaluation revealed that the Multi-TLC curriculum permitted a greater breadth of direct observation and assessment across competencies, maintained the previous learning objectives while also addressing additional ones, and was done so in a way that reduced the overall financial and human resource costs associated with the department's obstetrical emergency simulation curriculum. A Multi-TLC organisation of simulation curricula can facilitate efficient application of competency-based education principles.

Cost-effectiveness of community-based gendered advisory services to farmers: Analysis in Mozambique and Tanzania.

Rigorous impact evaluations on agricultural interventions in the developing world have proliferated in research of recent years. Whereas increased care in causal identification in such analyses is beneficial and has improved the quality of research in this field, much of the literature still fails to investigate the costs needed to achieve any benefits identified. Such understanding, however, would be crucial for drawing policy and programmatic conclusions from the research and for informing the allocation of public investments. Cost-effectiveness analysis (CEA) subjects both the cost side and the effects side of agricultural and rural interventions to technical scrutiny and unifies both sides in order to compare the relative cost-effectiveness of different modalities of a programme, of efforts to reach different target groups, or of efforts to achieve different outcomes. CEAs, while present in the health and education sectors, remain rare in agricultural and rural development research. This study contributes to filling the knowledge gap by conducting CEAs in a particular type of programmatic work in the agricultural sector-namely, interventions conducted as field experiments that bring a gender lens to community-based advisory services in African rural areas. Specifically, we consider two such programmes-one in Mozambique in which such advisory services aim to improve sustainable land management (SLM) practices in agricultural production, and the other in Tanzania to advise farmers on their land rights. Using CEA methods combined with econometric analysis based on randomised controlled trials, we find that the gendered modality is consistently more cost-effective than the basic modality when considering varied outcomes and target groups. However, for any given modality, it is more cost-effective to improve outcomes for men than for women. The structure of costs in the agricultural extension programme further allowed for a simulation of how cost-effectiveness would change if the programme were scaled up geographically. The results show that expansion of the basic modality of the SLM programme leads to improvements in cost-effectiveness, while the gendered modality displays nonlinear changes in cost-effectiveness along the expansion path, first worsening with initial scale-up and subsequently improving with further expansion.

Heat and Adult Health in China.

Given projected increases in the frequency of precipitation and temperature extremes in China, we examine the extent adults may be vulnerable to climate anomalies. We link nutrition, health, and economic data from the China Health and Nutrition Survey (1989-2011) to gridded climate data to identify which socioeconomic outcomes are particularly susceptible, including adult underweight incidence, body mass index, dietary intake, physical activity, illness, income, and food prices. We find warm temperatures augment the probability of being underweight among adults, with a particularly large impact for the elderly (ages > 60). Extremely dry and warm conditions produce a 3.3-percentage point increase in underweight status for this group. Consequences on nutrition coincide with changes in illness rather than dietary, income or purchasing power shifts. Social protection targeting areas prone to excessive heat may consider supplementing bundles of goods with a suite of health care provisions catering to the elderly.

Climate Variability and Inter-Provincial Migration in South America, 1970-2011.

We examine the effect of climate variability on human migration in South America. Our analyses draw on over 21 million observations of adults aged 15-40 from 25 censuses conducted in eight South American countries. Addressing limitations associated with methodological diversity among prior studies, we apply a common analytic approach and uniform definitions of migration and climate across all countries. We estimate the effects of climate variability on migration overall and also investigate heterogeneity across sex, age, and socioeconomic groups, across countries, and across historical climate conditions. We also disaggregate migration by the rural/urban status of destination. We find that exposure to monthly temperature shocks has the most consistent effects on migration relative to monthly rainfall shocks and gradual changes in climate over multi-year periods. We also find evidence of heterogeneity across demographic groups and countries. Analyses that disaggregate migration by the rural/urban status of destination suggest that much of the climate-related inter-province migration is directed toward urban areas. Overall, our results underscore the complexity of environment-migration linkages and challenge simplistic narratives that envision a linear and monolithic migratory response to changing climates.