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.

Research Capacity Strengthening in Sub-Saharan Africa: Recognizing the Importance of Local Partnerships in Designing and Disseminating HIV Implementation Science to Reach the 90-90-90 Goals.

Capacity building in implementation science is integral to PEPFAR's mission and to meeting the 90-90-90 goals. The USAID funded Project SOAR sponsored a 4 day workshop for investigators and governmental and non-governmental partners from 12 African countries. The workshop was designed to address both findings from a pre-workshop online needs assessment as well as capacity challenges across the capacity building pyramid, from individual skills to institutional systems and resources. Activities were output-oriented and skill based. An online survey evaluated sessions and changes in perceptions of needs; a majority of respondents strongly agreed that after the workshop, they better understood their personal and institutional capacity strengthening needs. Participants 'strongly agreed' that workshop content was relevant to their jobs (90%) and that they left the workshop with a specific plan for conducting future research (65%). Workshop results suggest that skill-building should be done in conjunction with systems capacity building within the cultural context.

Are you ready? A systematic review of pre-departure resources for global health electives.

BACKGROUND: There has been an exponential increase in the offering of short-term international field experiences in recent years in response to student demands for global health opportunities. Pre-departure preparation is an essential component to equip trainees with the adequate safety, wellness, and cultural competence needed to engage in a meaningful and mutually beneficial elective. This review seeks to quantify the plethora of pre-departure preparation training available to public health, clinical, and undergraduate trainees across the continuum of education for short-term experiences in low-and middle-income countries (LMICs). METHODS: We performed a systematic review of Pubmed, Embase, Web of Science, Scopus, and Ovid Global Health in February, 2018. A three-concept search was employed and included "global or international health"; "education or preparation of personnel/students"; and "field programs or travel." The study teamed used PRISMA reporting guidelines to conduct title and full-text reviews and conduct data extraction and analysis. RESULTS: The search returned 2506 unique articles. Of these, 55 met inclusion criteria and were included in the final review. Ninety one percent (91%) of articles focused on pre-departure trainings for medical students and residents. Nine thematic domains for short-term international field experiences emerged; culture, safety, and project-specific knowledge were the most frequently covered domains while mentorship, professionalism, and emotional wellness and culture shock were least common. Approximately half (53.3%) of studies specifically evaluated the pre-departure component of the international experience using a survey or evaluation form. Recommendations emerged from these evaluations including early engagement with international partners, inclusion of self-reflection exercises and site-specific content, and utilization of interactive approaches in learning. Some institutions face barriers to conducting pre-departure preparation such as lack of dedicated faculty, finances, and institutional support. CONCLUSIONS: Interest in pre-departure training for international experiences is growing but few programs conduct and publish evaluations of these trainings. Pre-departure trainings should be developed in partnership with receiving institutions and faculty and incorporate critical self- reflection throughout the experience. In addition to the experience itself, institutions need to evaluate these curricula to better understand how they influence trainees' capacity to effectively engage in LMIC settings.

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.

"The era of single disease cowboys is out": evaluating the experiences of students, faculty, and collaborators in an interdisciplinary global health training program.

BACKGROUND: Global Health is an inherently interdisciplinary field but overseas training in global health, particularly among health science institutions, has been an 'individual' or 'individual discipline' experience. Team-based training is an approach to global health education which is increasing in popularity; research on team-training demonstrates that teams are more productive than individuals. In 2015, the Johns Hopkins Center for Global Health (CGH) developed the Global Established Multidisciplinary Sites (GEMS) program, an interdisciplinary training program which was designed to establish a new norm in global health training by bringing interdisciplinary teams of faculty and students together to identify and solve complex global health challenges. This research aims to evaluate the program's first year and contribute to the literature on interdisciplinary team training. We conducted 22 in-depth interviews with students, faculty, and local collaborators from 3 GEMS project sites. Findings were analyzed for themes through a framework approach. RESULTS: The program exposed students, faculty, and collaborators to a wide range of disciplines in global health. Students' desire to learn how other disciplines contribute to global health solutions was an important motivator for joining GEMS; many participants including faculty and collaborators valued exposure to multiple disciplines. Mentorship and communication were a challenge across all teams in part due to members having distinct "disciplinary languages". Balancing disciplinary representation on teams and establishing work plans were also key challenges. CONCLUSIONS: Based on the data the CGH provides four recommendations for institutions developing global health interdisciplinary teams to optimize team functioning and address challenges in mentorship, language, and roles: 1) address interdisciplinary communication early, 2) develop work plans during group formation, 3) meet as a team prior to travel, and 4) establish regular check ins. This article provides first-hand reflections on interdisciplinary team experiences in a global context and provides a pathway for the development of innovative strategies in global health training.

Sustained adoption of water, sanitation and hygiene interventions: systematic review.

OBJECTIVE: To understand factors that influence sustained adoption of water, sanitation and hygiene (WASH) technologies or behaviours. METHODS: Systematic review of the current literature. Articles were gathered from databases of peer-reviewed articles and grey literature, and screened for relevance. After exclusion, we created a descriptive map of 148 articles and analysed in-depth 44 articles that had an explicit focus on promoting or evaluating sustained adoption or programme sustainability. Twenty-two of these articles met our definition of measuring sustained adoption. RESULTS: Definitions of sustained adoption varied widely and were often inadequate, making comparison of sustained adoption across studies difficult. The time frame for measurements of sustained adoption is frequently inadequate for examination of longer-term behaviour change. CONCLUSIONS: Ideally, an evaluation should specify the project period and describe the context surrounding adoption, make measurements at multiple time points, diversify measurement methods and describe and measure a range of factors affecting sustained adoption. Additional consideration needs to be given to developing behaviour change models that emphasise factors related to sustained adoption, and how they differ from those related to initial adoption.

Multiple entries and exits and other complex human patterns of insecticide-treated net use: a possible contributor to residual malaria transmission?

BACKGROUND: Increased insecticide-treated net (ITN) use over the last decade has contributed to dramatic declines in malaria transmission and mortality, yet residual transmission persists even where ITN coverage exceeds 80%. This article presents observational data suggesting that complex human net use patterns, including multiple entries to and exits from ITNs by multiple occupants throughout the night, might be a contributing factor. METHODS: The study included dusk-to-dawn observations of bed net use in 60 households in the Peruvian Amazon. Observers recorded number of net occupants and the time and number of times each occupant entered and exited each net. The study team then tabulated time of first entry, total times each net was lifted, and, where possible, minutes spent outside by each occupant. RESULTS: The sample included 446 individuals and 171 observed sleeping spaces with nets. Household size ranged from 2 to 24 occupants; occupants per net ranged from 1 to 5. Nets were lifted a mean 6.1 times per night (SD 4.35, range 1-22). Observers captured substantial detail about time of and reasons for net entry and exit as well as length of time and activities undertaken outside. CONCLUSIONS: These findings suggest that the ITN use patterns observed in this study may contribute to residual transmission. As a result, respondents to net use surveys may truthfully report that they slept under a net the previous night but may not have received the anticipated protection. More research is warranted to explore the impact of this phenomenon. Concurrent entomological data would help assess the magnitude of the effect.

Active transport of bile acids decreases mucin 2 in neonatal ileum: implications for development of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency of premature infants, but its etiology remains unclear. We have previously shown that mucin 2 (Muc2) positive goblet cells are significantly decreased in NEC. We have also shown that ileal bile acids (BAs) are significantly increased during the development of this disease. Because BAs can affect mucins, we hypothesized that elevated ileal BAs contribute to decreased Muc2 in experimental NEC. The role of Muc2 in NEC was evaluated in Winnie +/+ mice, a strain that produces aberrant Muc2. Muc2 and trefoil factor 3 (Tff3) were assessed in neonatal rats subjected to the NEC protocol when bile acids were removed, and in ileal explants from newborn and older rats cultured with and without BAs. Further, the role of active transport of BAs was determined using neonatal rats given the apical sodium dependent bile acid transporter (Asbt) inhibitor SC-435 and in neonatal Asbt knockout mice subjected to the NEC protocol. Mice with aberrant Muc2 had significantly greater incidence and severity of NEC. Using both in vivo and ex vivo techniques, we determined that BAs decrease Muc2 positive cells in neonatal but not older ileum. However, Tff3 positive cells are not decreased by BAs. In addition, active transport of BAs is required for BAs to decrease Muc2 in immature ileum. These data show that functional Muc2 plays a critical role in the prevention of NEC and BAs can potentiate the decreased Muc2 in disease development. Further, BAs have a more profound effect on Muc2 in immature versus older ileum, which may explain at least in part why NEC occurs almost exclusively in premature infants.