Mind the Gap! Working Toward Gender Equity in Pediatric and Congenital Heart Disease: Present and Future.

Evidence from medicine and other fields has shown that gender diversity results in better decision making and outcomes. The incoming workforce of congenital heart specialists (especially in pediatric cardiology) appears to be more gender balanced, but past studies have shown many inequities. Gender-associated differences in leadership positions, opportunities presented for academic advancement, and recognition for academic contributions to the field persist. In addition, compensation packages remain disparate if evaluated based on gender with equivalent experience and expertise. This review explores these inequities and has suggested individual and institutional changes that could be made to recruit and retain women, monitor the climate of the institution, and identify and eliminate bias in areas like salary and promotions.

Effect of play-based intervention on children's mental status and caregiver involvement during hospitalization: findings from Pakistan.

BACKGROUND: The nurturing care framework (NCF) encompasses responsive caregiving, health, nutrition, safety and security by parents and other caregivers. It improves health, development and wellbeing of children. A hospital environment can be detrimental to the developmental and emotional needs of children hence NCF can be applied to hospitalized children. OBJECTIVE: The objective was to determine if (i) play stimulation intervention mediated by non-specialist providers (caregivers) improves mental status of children who are hospitalized; (ii) to examine if difference varies between different providers and iii) if there is variation based on child age and criticalness of illness. METHOD: A one-group pretest-posttest research was carried out using purposive sampling in a pediatric unit in Karachi, Pakistan, from November 2017 to December 2019. Children aged 3 months to 6 years were offered play stimulation by trainee psychologists. The outcome was measured through an observation tool, the Mental Status Examination Scale (MSE-S) developed for the study. RESULTS: A total of 524 sessions were delivered to 351 children. Significant mean difference was observed on MSE-S before and after the intervention when it was provided by trainees (9.95, CI = 8.11, 11.7), mothers (mean difference = 5.86, CI = 5.30, 6.42), fathers (mean difference = 5.86, CI = 4.48, 7.24) and non-specialist providers [caregivers (mean difference = 5.40, CI = 3.91, 6.89). Significant differences in mean was observed on MSE-S across different age groups and criticalness of illness. CONCLUSION: It was concluded that play stimulation not only affects the behaviour of children but also varies when delivered by caregivers and trainees. Hence, interventions that involve parents are feasible.

Raising the issue of quality in implementation science reporting in global health: Implications for health planning and practice.

Implementation outcomes, which focus on the barriers to, and facilitators and processes of healthcare delivery, are critical to translating research evidence to health planning and practice and to improving healthcare delivery. This article summarises key quality issues in reporting of implementation science outcomes within global health and describes the ways in which this presents a challenge for shifting health planning and practice across low-resource health systems. This article also suggests that the wider use of reporting guidelines for implementation outcomes could help address this issue.

Mentorship as an overlooked dimension of research capacity strengthening: how to embed value-driven practices in global health.

Mentorship in global health remains an overlooked dimension of research partnerships. Commitment to effective mentorship models requires value-driven approaches. This includes having an understanding of (1) what mentorship means across different cultural and hierarchical boundaries in the health research environment, and (2) addressing entrenched power asymmetries across different aspects including funding, leadership, data and outputs, and capacity strengthening. Existing guidance towards equity and sustainability fails to inform how to navigate complex relationships which hinder effective mentorship models. We focus this perspective piece on human capacity strengthening in research partnerships through mentorship. Using a case study of a research partnership, we describe the lessons learnt and the challenges faced in the mentor mentee relationship while maintaining an effective and sustainable partnership. Human capacity strengthening must research projects and collaborations, and recognise local leadership and ownership. To be transformative and effective, practices need to be driven by common values across research teams.

The benefits of nurturing care interventions on early child development and care: findings from a quasi-experimental study in a humanitarian setting.

BACKGROUND: The study objective was to determine if a nurturing care parenting intervention delivered in a humanitarian setting in Rwanda would benefit early development, learning, and care outcomes for young children under five years and their caregivers compared to standard care. METHODOLOGY: Rwanda's Mugombwa, Kansi, and Kigeme refugee camps and host communities implemented the parenting program. Via a quasi-experimental research design, the study assessed the effects of intervention delivered as a high dose (HD: 12 group sessions and four home visits) or low dose (LD: 6 group sessions and two home visits) on child and caregiver outcomes compared to the control group from similar settings receiving standard care. The Ages and Stages Questionnaires-3 (ASQ-3) assessed child development outcomes. The Multiple Indicator Cluster Survey questionnaire assessed parenting practices concerning early learning and stimulation. FINDINGS: The assessment included 733 children and families in total: HD = 314, LD = 240, control = 179. The researchers found no significant difference in child development scores between the intervention and control groups. Significantly higher proportion of caregivers exposed to HD and LD packages had engaged in early learning and stimulation practices compared to the control group, respectively, with 211(67.2%), 148 (61.7%) vs. 66 (36.9%), p < 0.001 caregivers engaged in 4 or more activities in the past three days. Similarly, on responsive feeding items, a higher percentage of HD and LD group caregivers were engaged in positive behaviours compared to the control group: 164 (52.2%), 108 (45%) vs. 62 (34.6%), p = 0.001. The study found no difference between the study arms regarding caregiver mental health. CONCLUSION: Parenting programmes in humanitarian settings can improve nurturing care practices, even with a low dose, which is essential to strengthening children's resilience in at-risk conditions. Further studies in humanitarian contexts are crucial to understand the implementation needs in sensitive contexts.

Implementation evaluation of a medical student-led intervention to enhance students' engagement with research: Findings and lessons learned.

INTRODUCTION: Medical colleges globally have student organizations that serve to enable students' involvement in research. However, details of their approach and activities are seldom published to serve as learning for student organizations in other settings. The Student Research Forum (SRF), a student organization based at a private medical school in Pakistan aims to facilitate students in acquiring research skills. Following the observation of a downward trajectory of student initiative and interest, SRF leadership restructured the organization and improve its impact. This study describes the development and implementation evaluation of the interventions. METHODOLOGY: The operational framework was revised using the Theory of Change by the core group. Major interventions included enhanced social media and outreach coordination, research workshops, journal clubs, and mentorship to increase research output, mentorship opportunities, and knowledge of medical research; ultimately improving quality in research. The outcomes generated over the course of the study's duration from July 2019 to September 2021 were analyzed using the process metrics of reach, adoption, and efficacy. RESULTS: As a result of the interventions, SRF expanded its reach by conducting a total of 41 events during the duration of the study, facilitated by social media growth on each of SRF's online platforms, with a 300% increase in followers on Facebook, and a nationwide network of 91 student ambassadors. An annual workshop series taught research skills to more than 3800 participants. Students leading their own events, SRF featuring international speakers, and the abstracts submitted to SRF's annual conference, along with the conference's reach of 10,000 students, are seen as improvements in the ToC-informed interventions' adoption. The efficacy of the interventions manifested as the REACH program allocated 56 research projects to vetted applicants. CONCLUSION: The applied interventions have accelerated SRF's progress towards achieving its long-term outcome of increased quality in research as translated by increased research output quantity, mentorship, and knowledge of medical research. Further evaluation is required to assess the success of the ToC. As SRF continues to grow, a continued analysis of the implementation outcomes is imperative to gauge its effectiveness.

Antiracism in leading public health universities, journals and funders: commitments, accountability and the decision-makers.

INTRODUCTION: Two years since the murder of George Floyd, there has been unprecedented attention to racial justice by global public health organisations. Still, there is scepticism that attention alone will lead to real change. METHODS: We identified the highest-ranked 15 public health universities, academic journals and funding agencies, and used a standardised data extraction template to analyse the organisation's governance structures, leadership dynamics and public statements on antiracism since 1 May 2020. RESULTS: We found that the majority of organisations (26/45) have not made any public statements in response to calls for antiracism actions, and that decision-making bodies are still lacking diversity and representation from the majority of the world's population. Of those organisations that have made public statements (19/45), we identified seven types of commitments including policy change, financial resources, education and training. Most commitments were not accompanied by accountability measures, such as setting goals or developing metrics of progress, which raises concerns about how antiracism commitments are being tracked, as well as how they can be translated into tangible action. CONCLUSION: The absence of any kind of public statement paired with the greater lack of commitments and accountability measures calls into question whether leading public health organisations are concretely committed to racial justice and antiracism reform.

The predictive validity of Bayley Scales of Infant and Toddler Development-III at 2 years for later general abilities: Findings from a rural, disadvantaged cohort in Pakistan.

Using data from a rural cohort in Pakistan (N = 1298), the study examined the predictive validity of the Bayley Scales of Infant and Toddler Development (BSID) 3rd edition on later tests of general abilities. The BSID III subscales (cognitive, language and motor) were administered at 2 years; general ability was assessed using the Verbal, Performance and Full-Scale score from the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) III at 4 years, and the Fluid Reasoning Index (FRI) from the Wechsler Intelligence Scale for Children (WISC) V at 8 years. The combined BSID subscales explained 15% of the variation of the WPPSI III full scale, 16% of the Verbal scale, 7% of the Performance scale and 1% of the FRI. BSID III scores at 24 months should be used with caution to predict future intellectual abilities.

Implementation evaluation of a leadership development intervention for improved family experience in a private paediatric care hospital, Pakistan.

BACKGROUND: A study from a tertiary care center in Pakistan demonstrated that a leadership development intervention led to improved family experience of care outcomes. The objective of the current paper is to assess the implementation of this intervention and identify barriers and facilitators to inform sustainability and scalability. METHODS: A working group designed the intervention using a theory-of-change model to strengthen leadership development to achieve greater employee engagement. The interventions included: i) purpose and vision through purpose-driven leadership skills trainings; ii) engaging managers via on-the-job mentorship programme for managers, iii) employee voice i.e., facilitation of upward communication to hear the employees using Facebook group and subsequently inviting them to lead quality improvement (QI) projects; and iv) demonstrating integrity by streamlining actions taken based on routine patient experience data. Implementation outcomes included acceptability, adoption, fidelity across degree & quality of execution and facilitators & barriers to the implementation. Data analyzed included project documentation records and posts on the Facebook group. Analysis indicated acceptability and adoption of the intervention by the employees as178 applications for different QI projects were received. Leadership sessions were delivered to 455 (75%) of the employees and social media communication was effective to engage employees. However, mentorship package was not rolled out nor the streamlined processes for action on patient experience data achieved the desired fidelity. Only 6 QI projects were sustained for at least a year out of the 18 approved by the working group. Facilitators included leadership involvement, real-time recognition and feedback and value-creation through participation by national and international celebrities. Challenges identified were the short length of the intervention and incentives not being institutionalized. The authors conclude that leadership development through short training sessions and on-going communications facilitated by social media were the key processes that helped achieve the outcomes. However, a long-term strategy is needed for individual managerial behaviours to sustain.

Corrigendum: A Nationwide Virtual Research Education Program for Medical Students in Pakistan: Methodological Framework, Feasibility Testing, and Outcomes.

[This corrects the article DOI: 10.3389/fpubh.2021.812130.].

Scaling Nurturing Care Interventions in the Health Sector: A Theory of Change Perspective.

Nurturing care interventions postulated on strengthening caregiver-child relationships have proven to be effective for improving early childhood development outcomes in low- and middle-income countries. Hence, a scale-up of the interventions has been recommended with an emphasis on the health sector given the contact with families in the critical first 3 years of life. However, an effective scale-up of an integrated intervention through healthcare requires a theory of change approach elucidating pathways of sustainable change. From this viewpoint, I reflect on my experience of scaling the intervention in a private pediatric care setting. I realized that buy-in from the health sector required realization of benefits to include health outcomes framed as the potential to improve the quality of life and the process of recovery; sustainable behavior change required a culture that promoted nurturing care highlighting the role of leadership; subsequently improving the experience of frontline staff and at an individual level, this could be achieved through the provision of supportive supervision-rooted in a framework of compassion. The lessons learned are shared to be considered for future integration efforts.

Funders: The missing link in equitable global health research?

Global health research is mired by inequities, some of which are linked to current approaches to research funding. The role of funders and donors in achieving greater equity in global health research needs to be clearly defined. Imbalances of power and resources between high income countries (HICs) and low- and middle-income countries (LMICs) is such that many funding approaches do not centre the role of LMIC researchers in shaping global health research priorities and agenda. Relative to need, there is also disparity in financial investment by LMIC governments in health research. These imbalances put at a disadvantage LMIC health professionals and researchers who are at forefront of global health practice. Whilst many LMICs do not have the means (due to geopolitical, historical, and economic reasons) for direct investment, if those with means were to invest more of their own funds in health research, it may help LMICs become more self-sufficient and shift some of the power imbalances. Funders and donors in HICs should address inequities in their approach to research funding and proactively identify mechanisms that assure greater equity-including via direct funding to LMIC researchers and direct funding to build local LMIC-based, led, and run knowledge infrastructures. To collectively shape a new approach to global health research funding, it is essential that funders and donors are part of the conversation. This article provides a way to bring funders and donors into the conversation on equity in global health research.

Generating Evidence From Contextual Clinical Research in Low- to Middle Income Countries: A Roadmap Based on Theory of Change.

Along with inadequate access to high-quality care, competing health priorities, fragile health systems, and conflicts, there is an associated delay in evidence generation and research from LMICs. Lack of basic epidemiologic understanding of the disease burden in these regions poses a significant knowledge gap as solutions can only be developed and sustained if the scope of the problem is accurately defined. Congenital heart disease (CHD), for example, is the most common birth defect in children. The prevalence of CHD from 1990 to 2017 has progressively increased by 18.7% and more than 90% of children with CHD are born in Low and Middle-Income Countries (LMICs). If diagnosed and managed in a timely manner, as in high-income countries (HICs), most children lead a healthy life and achieve adulthood. However, children with CHD in LMICs have limited care available with subsequent impact on survival. The large disparity in global health research focus on this complex disease makes it a solid paradigm to shape the debate. Despite many challenges, an essential aspect of improving research in LMICs is the realization and ownership of the problem around paucity of local evidence by patients, health care providers, academic centers, and governments in these countries. We have created a theory of change model to address these challenges at a micro- (individual patient or physician or institutions delivering health care) and a macro- (government and health ministries) level, presenting suggested solutions for these complex problems. All stakeholders in the society, from government bodies, health ministries, and systems, to frontline healthcare workers and patients, need to be invested in addressing the local health problems and significantly increase data to define and improve the gaps in care in LMICs. Moreover, interventions can be designed for a more collaborative and effective HIC-LMIC and LMIC-LMIC partnership to increase resources, capacity building, and representation for long-term productivity.

Development of an on-job mentorship programme to improve nursing experience for enhanced patient experience of compassionate care.

BACKGROUND: Evidence suggests improvement in nursing staff satisfaction, competence, and retention after implementation of evidence-based mentorship programmes. When guided by a framework of compassion, mentoring as a caring action can not only build healthy, transformative relationships but a similar behavior is reciprocated to patients which subsequently can drive patient experience of care. However, examples of on-job mentorship programs for nurses in low- and middle-income countries (LMIC) are limited. OBJECTIVE: The objective of the study was to develop an on-job nursing mentorship programme using a compassionate framework aimed at improving nurses' experience and thus enhancing patient experience in a tertiary care hospital in Pakistan. METHODS: Designed as an intervention development study, it was completed between January 2018-December 2019. The programme was developed by a team composed of service and nursing leadership, director patient experience of care and a compassion specialist using a theory of change model. The package followed a series of steps, a) identification of a framework, b) creation of working group c) needs assessment and d) multiple meetings to frame the model followed by implementing the preconditions for roll-out of the programme with the frontline staff. RESULTS: The eventual outcome was improving the patient's experience of compassion while the intermediate outcome was to have nurses demonstrate compassionate care. The pre-conditions were identified as: recruitment of staff with appropriate skills for pediatric care, provision of compassionate experience to the frontline nurses by addressing their specific pain points, development of competent head nurses as supervisors and creation of a compassionate culture. To ensure the pre-conditions, various interventions were planned with some implemented through the course of the study while others are in the process of being rolled out. These involved, inclusion of pediatric compassion specific module during orientation of new hires, creation of space to talk about compassionate skills with staff, provision of trainings and mentorship to create competent head nurses, and creating a culture that promoted and recognized compassionate care values. CONCLUSION: The approach helped to delineate feasible pathways for an on-job compassionate mentorship programme enhancing routine supervisors' role as facilitators of compassionate care.

Validation of the Infant and Young Child Development (IYCD) Indicators in Three Countries: Brazil, Malawi and Pakistan.

BACKGROUND: The early childhood years provide an important window of opportunity to build strong foundations for future development. One impediment to global progress is a lack of population-based measurement tools to provide reliable estimates of developmental status. We aimed to field test and validate a newly created tool for this purpose. METHODS: We assessed attainment of 121 Infant and Young Child Development (IYCD) items in 269 children aged 0-3 from Pakistan, Malawi and Brazil alongside socioeconomic status (SES), maternal educational, Family Care Indicators and anthropometry. Children born premature, malnourished or with neurodevelopmental problems were excluded. We assessed inter-rater and test-retest reliability as well as understandability of items. Each item was analyzed using logistic regression taking SES, anthropometry, gender and FCI as covariates. Consensus choice of final items depended on developmental trajectory, age of attainment, invariance, reliability and acceptability between countries. RESULTS: The IYCD has 100 developmental items (40 gross/fine motor, 30 expressive/receptive language/cognitive, 20 socio-emotional and 10 behavior). Items were acceptable, performed well in cognitive testing, had good developmental trajectories and high reliability across countries. Development for Age (DAZ) scores showed very good known-groups validity. CONCLUSIONS: The IYCD is a simple-to-use caregiver report tool enabling population level assessment of child development for children aged 0-3 years which performs well across three countries on three continents to provide reliable estimates of young children's developmental status.