Prenatal exposure to pesticides has been linked to adverse neurodevelopmental outcomes. Gaps exist in the current literature about the timing and magnitude of exposures that result in these adverse outcomes.The Study of Asian Women and their Offspring’s Development and Environmental Exposures (SAWASDEE) cohort was established to investigate the impact of prenatal exposure to pesticides on early indicators of cognitive and motor skills, inhibitory control, emotion regulation, and memory that have been found to be important in the development of subsequent neurobehavioral and neurodevelopmental diseases. The overarching goal is to find earlier predictors of potential adverse neurologic outcomes in order to enable earlier interventions that could result in better outcome prognoses.Recruitment of this prospective, longitudinal birth cohort began in July 2017 and was completed in June 2019 in Chom Thong and Fang, 2 farming districts in Chiang Mai Province in northern Thailand. Follow-up of the study participants is ongoing. During pregnancy, 7 questionnaires were administered. Time-resolved biospecimen samples were collected monthly (for urine) and during each trimester (for blood) during antenatal care visits. Medical records were abstracted. Infants were administered the NICU Network Neurobehavioral Scale (NNNS) test at 1 month of age. A total of 322 mother-child pairs completed the NNNS test. All children will be followed until 3 years of age and undergo a series of neurodevelopmental tests. We will complete several additional exposure related analyses.A total of 1298 women were screened, and of those, 394 (30.35%) women were enrolled. The mean gestational age at enrollment was 9.9 weeks (SD 2.6). Differences in literacy were observed between Chom Thong and Fang participants. In Fang, about 54 of 105 (51.4%) participants reported being able to read in Thai compared to about 206 of 217 (94.9%) participants in Chom Thong. The percentages were comparable for reporting to be able to write in Thai.This longitudinal birth cohort study will inform risk assessment standards for pregnant women in Thailand and other countries. Building awareness of how insecticide exposure during specific windows of pregnancy affects the neurodevelopmental trajectories of children in developing countries is a specific need recognized by the World Health Organization.DERR1-10.2196/31696 Prenatal exposure to mixtures of neurotoxic pesticides is prevalent worldwide and has the potential to disrupt and irreversibly alter neurologic development -3. In 20Previous human and animal studies have reported that following exposure, neurotoxic insecticides, including pyrethroids and OPs, are able to cross the placental barrier and enter the fetal blood stream . Until nThe Study of Asian Women and their Offspring’s Development and Environmental Exposures (SAWASDEE) study was conceived to fill some of these knowledge gaps preventing effective policy implementation. The SAWASDEE study is a prospective, longitudinal birth cohort study evaluating pesticide exposure in farmworker women in northern Thailand enrolled during their first trimester of pregnancy and evaluating neurodevelopment in their children at multiple time points until 3 years of age. Our study was designed to collect uniquely refined pesticide exposure data to define critical windows of effect during pregnancy and to evaluate novel neurological testing parameters that could predict a child’s neurodevelopmental trajectory. The study is a multi-institute initiative and builds upon an existing structure of collaboration and capacity building between Emory , Rutgers , Chiang Mai , and Chulalongkorn  Universities. Our cohort includes the collection of robust prenatal and postnatal exposure assessment data; extensive biospecimens, including monthly maternal urine samples and trimester-specific maternal blood; and questionnaire data to enable identification of sensitive windows of exposure to pesticides on development. Children born as part of the birth cohort are followed longitudinally until the age of approximately 3 years to test the hypothesis that prenatal exposure may alter neurodevelopment and that the neurodevelopmental trajectory can be estimated by first-year testing parameters.Because pesticides are not expected to selectively impact a specific brain region, the study is designed to assess neurodevelopmental trajectories using behavioral measures of infant and early childhood function that reflect underlying neural substrates of visual attention, regulation of emotion, memory, and inhibitory control. This approach integrates the measurement of cognitive and emotional development, recognizing that the regulation of biologically based emotional reactivity, such as anger or fear, is necessary for successful cognitive development. Moreover, the child must develop the ability to delay or inhibit immediate responses in order to achieve higher-level cognitive skills .The purpose of this paper is to provide a comprehensive overview of the SAWASDEE cohort profile as a research resource for potential collaborations, including a description of the data collected, a description of baseline characteristics, and a summary of the future plans for the cohort.The SAWASDEE study is based on a longitudinal birth cohort of women residing in northern Thailand who are agricultural workers or live on a working farm. The exposures of interest are pyrethroids and OPs, while the outcomes of interest are birth outcome and child neurodevelopment. All study procedures were reviewed and approved by the institutional review board at Emory University (with Rutgers reliance) and the ethics review committee at the Research Institute for Health Sciences, Chiang Mai University . Informed consent was obtained from all study participants prior to enrollment.Recruitment occurred in Chiang Mai Province in northern Thailand because of its robust agricultural sector and its generalizability to other low-/middle-income countries (LMICs) that are similarly reliant on agriculture. The primary crops in Chiang Mai include rice, tangerines, longans, lychee, and ornamental flowers, with their use of pesticides varying greatly with the crop grown. For example, fruits trees require a larger application amount in a shorter application period. Conversely, rice crops require insecticide application more regularly during the growing season but at lower quantities. These 2 types of pesticide application scenarios  can be easily studied in Chiang Mai Province by focusing on 2 of its distinct districts: (1) Chom Thong and (2) Fang. Chom Thong and Fang are both agricultural communities located about 60 and 150 km, respectively, outside of Chiang Mai City. Chom Thong crops include longans, cut flowers, vegetables, and rice, while in Fang, located in the mountainous region near the Myanmar border, tangerines are the predominant crop. The differences in crops grown in the corresponding districts create a sort of natural experiment of exposure, allowing us to evaluate the differences in these scenarios.Prior to recruitment, we developed and culturally validated, where appropriate, a detailed set of standard operating procedures (SOPs) and questionnaires. SOPs were developed for sample identification numbers and label generation, biospecimen collection and processing, laboratory testing, and quality assurance and control (QA/QC) procedures, including field blank sample collection, bench-level QC and blank samples, sample compositing, sample randomization for analysis, and neurological testing. In addition, to facilitate sample processing and efficient transfer of samples to Chiang Mai University, we scoped and rented apartments that we outfitted as satellite laboratories we called “SAWASDEE houses” located in each of the districts.Recruitment began in July 2017 and was completed in June 2019. Women were recruited at community and district hospitals in both districts by trained study nurses. Nurses administered an initial screening questionnaire to determine eligibility of the pregnant women. Women were eligible for participation if they (1) were an agricultural worker or lived within 50 m of an agricultural field, (2) had a Thai identification card permitting hospital and antenatal clinic access, (3) resided in their regional district for ≥6 months and planned residence at least 3 years after delivery, (4) spoke Thai at home, (5) were in good general health , (6) consumed fewer than 2 alcoholic beverages per day and did not use illegal drugs , (7) andWe screened 1289 women, and of those, 398 (30.88%) met our enrollment criteria and of which 394 (98.9%) were enrolled. Of these 394 participants, 322 (81.7%) completed all data collection  through Trained research assistants (RAs) and nurses administered each questionnaire in Thai. These questionnaires included a recruitment survey to determine eligibility (screening questionnaire); an intake questionnaire to collect baseline descriptive statistics; an extensive exposure questionnaire administered during early, middle, and late pregnancy that roughly corresponded to trimesters; and a Knowledge, Attitude, and Practices (KAP) survey of pesticides, collected during the first and third trimesters. The exposure questionnaires, which were validated and used in our pilot study , includeThe following information was extracted from medical records: early pregnancy weight and weight gain, parity, past obstetric history, planned pregnancy, smoking and alcohol consumption, marital status, occupation, history of illness, and prenatal visit history, which included gestational age at first visit, subsequent visit dates, doctor-assessed nutritional status, and compliance with micronutrient supplementation regimens. These data were updated at each of the visits to track a variety of indicators, including maternal nutritional status (using weight gain as a surrogate) and significant stressors that could complicate the exposure-effect evaluation. Data extracted from participant birth records included sex, birth weight, length, gestational age, and head circumference; appearance, pulse, grimace, activity, and respiration (APGAR) scores; type and route of delivery; anesthesia; and information about maternal and neonatal complications.Biospecimens collected from enrolled participants are shown in Blood, serum, urine, and hair were used for exposure assessment, with urine being the primary matrix used. Blood was used for susceptibility biomarker analysis , and placenta tissue was used for transcriptomics analysis.To provide trimester-specific exposure measures during pregnancy, while still keeping the study costs reasonable, we created trimester-specific urine composites from each participant but still retained the original discrete samples for later use. DAPs, TCPY, and 3PBA were measured in these maternal composited urine samples  using esExtensive neurodevelopment examination of each child was conducted by trained neuropsychologists at the following time points: 1, 4, 7, 12, 18, 24, and 36 months .Assessment at these intervals represents a significant departure from previous studies of pesticide exposure and will allow examination of how pesticides may alter the neurodevelopmental trajectory of children. For tests administered at more than 1 developmental period, age-appropriate adjustments were made to increase the difficulty of the test. Infant and child responses were either scored in real time in the case of visual habituation tests or scored from digital recordings when testing was complete. Interrater reliabilities were conducted monthly for all tests using different videos each month and independent scoring by psychologists to maintain reliability among testers. All tests were routinely recorded to allow recheck procedures and scoring. The neurodevelopmental measures used in our study included those traditionally used in other birth cohort studies  but also included tests of visual habituation at 4 and 7 months as indicators of visual attention and information processing, followed by tests of infant memory and executive function  and 3. TThe Home Observation for the Measurement of the Environment (HOME) is a structured interview conducted with the primary caretaker and child in the home of each participant to observe and assess the physical environment, family structure/relationships, and learning environment for the child . HOME wat test at the .05 significance level. The longitudinal design of our study provides further power than estimated. Based on these calculations, 300 infants should provide enough power to detect differences between groups.We assumed that differences in neurobehavioral estimates for infants of mothers working on fruit/vegetable farms and those with mothers working on rice farms will be similar to differences observed between infants from preterm versus full-term pregnancies. Thus, Rose et al  providedThe baseline characteristics of the study participants were analyzed and reported by study location (Chom Thong and Fang). All analyses were performed using SAS V.9.4 .In total, 1289 pregnant women were administered the recruitment-screening questionnaire. The primary reasons screened individuals were not eligible were as follows: (1) their gestational age was more than 16 weeks  or (2) they were agricultural workers or lived within 50 m of an agricultural field . Of those individuals eligible for the study , 394 (98.9%) women provided consent to join the study and were enrolled . Among tP<.05) between participants from Chom Thong and Fang.Of the 322  mother-child pairs with a completed NNNS, the mean age of SAWASDEE study participants at enrollment was 25 years (SD 5.3); see The median and range of exposure measures and PON1 activity categorizations are shown in The SAWASDEE study was successfully established to fill critical gaps in the literature by measuring exposure multiple times during each trimester of pregnancy, while tracking neurodevelopmental trajectories in infancy and early childhood. By establishing the association between exposure biomarkers during early-to-late pregnancy and these neurodevelopmental trajectories, we will be able to examine windows of increased susceptibility to pesticide exposure. This information may result in specification of vulnerability, resulting in recommendations for reduction in adverse neurodevelopmental outcomes.Our enrollment and participant rates were notable, provided the low population density and complexities of travel in these regions. The terrain is mountainous and winding; participants had to often rely on public transportation to make the study visits. We tried to align our study visits as closely as possible to their antenatal visits for convenience and reimbursed participants for travel. However, in some of the worst cases, participants traveled for up to 4 hours to attend these visits. Their loyalty to our study was largely a result of the close relationship our study nurses and RAs developed with the participants and the immense trust our participants had in them. Although we believe that the relationships that were established between field staff and study participants were essential in preserving study retention, it is also possible there were behavioral changes in pesticide practices over time due to unintentional influence by field staff or involvement in the study. Analysis of the KAP questionnaires from our pilot study revealed that there was an increase in pesticide-related knowledge among pregnant women and that influenced changes in pesticide practices . In thisOur study is not without limitations. We may have some differential bias in gestational age among sites, which we described above. There is potential for exposure misclassification because of the contribution of preformed environmental metabolites to the measured urinary metabolite levels. However, given that our population is experiencing occupational exposures that occur after known pesticide application events, we expect this contribution to be smaller than if we were evaluating background dietary exposures. We also did not measure all pesticides to which participants may have been exposed. Although we have basic dietary information for mothers during pregnancy, we could not conduct a thorough assessment of dietary information, such as a food frequency questionnaire, largely because of funding issues. In addition, some of our neurological tests have no known cultural norms for comparison, but our pilot studies have provided insight into how this can be addressed in our data analyses .Despite our study’s limitations, this is still the first study to evaluate these neurodevelopmental outcomes in Thailand and to provide refined exposure measurements during pregnancy.Our study has several strengths. We have time-resolved and highly sensitive exposure measures from all trimesters of pregnancy in our participants. This includes 2 distinct exposure scenarios: long-term, lower-dose pesticide exposure, and high-dose, intermittent pesticide exposure. The robustness of exposure and outcome data will allow investigators to evaluate numerous scientific questions and ultimately improve the generalizability of associations between pesticide exposure and neurodevelopmental outcomes. The majority of previous studies have been conducted using cohorts from high-income countries and examination in LMICs is lacking. The success of our study recruitment and retention is largely attributed to the strong community-centered nature and the respect shown to the field research staff by study participants. We found this to be especially true within the Thai culture—individuals have a high level of respect for health care practitioners. The study also includes highly refined neurodevelopment assessment with sensitive measures of early neurointegrity that measure the basis of later cognitive and motor development. Previous studies have used clinical measures that are relatively less sensitive to subtle and early adverse effects. We can evaluate windows of vulnerability as they relate to specific neurodevelopmental processes and the trajectory of development. In addition, this study assesses not only cognitive and motor skills but also inhibitory control and emotion regulation, not previously studied with behavioral measures. The NNNS, in addition to the other neurodevelopmental assessments included in the study, creates a robust database of neurodevelopment, which can be used to evaluate several scientific questions related to neurodevelopment, including evaluating trajectories of neurodevelopment. The prospective longitudinal data in our study present a valuable resource for evaluating many scientific questions. The SAWASDEE study offers potential collaborators an opportunity to work with robust estimates of exposure and neurodevelopment. The number of supplemental studies that are part of the SAWASDEE study continues to increase, and thus, the database continues to grow, offering investigators an opportunity to test several hypotheses.The SAWASDEE birth cohort study provides information essential for risk assessment paradigms addressing the risk of prenatal pesticide exposure and neurodevelopment. The cohort is unique in that it is designed with highly refined exposure and neurodevelopmental data with the ability to determine neurodevelopmental trajectories early in infancy with the hope of early intervention. Successful enrollment followed by high rates of retention and participation in the study provides a unique opportunity for evaluating maternal pesticide exposure and child neurodevelopmental outcomes.


Introduction: Research capacity building is a critical component of professional development for pediatrician scientists, yet this process has been elusive in the literature. The ECHO IDeA States Pediatric Clinical Trials Network (ISPCTN) seeks to implement pediatric trials across medically underserved and rural populations. A key component of achieving this objective is building pediatric research capacity, including enhancement of infrastructure and faculty development. This article presents findings from a site assessment inventory completed during the initial year of the ISPCTN.Methods: An assessment inventory was developed for surveying ISPCTN sites. The inventory captured site-level activities designed to increase clinical trial research capacity for pediatrician scientists and team members. The inventory findings were utilized by the ISPCTN Data Coordinating and Operations Center to construct training modules covering 3 broad domains: Faculty/coordinator development; Infrastructure; Trials/Research concept development.Results: Key lessons learned reveal substantial participation in the training modules, the importance of an inventory to guide the development of trainings, and recognizing local barriers to clinical trials research.Conclusions: Research networks that seek to implement successfully completed trials need to build capacity across and within the sites engaged. Our findings indicate that building research capacity is a multi-faceted endeavor, but likely necessary for sustainability of a unique network addressing high impact pediatric health problems. The ISPCTN emphasis on building and enhancing site capacity, including pediatrician scientists and team members, is critical to successful trial implementation/completion and the production of findings that enhance the lives of children and families. Clinical trial funding has historically been confined to large academic centers with largely urban populations and limited age groups of children . LikewisThe ECHO IDeA States Pediatric Clinical Trials Network (ISPCTN), funded and established by the National Institutes of Health (NIH) in 2016 as a component of the NIH Environmental Influences on Child Health Outcomes (ECHO) program, is unique in its geographic composition and diverse in its ethnic and racial makeup . CharactCapacity building has been defined as “a process of individual and institutional development which leads to higher levels of skills and greater ability to perform useful research” . Within What can be determined from the existing literature, however, is that several barriers to building research capacity include a lack of funding, insufficient physical resources, limited research experience and expertise, competing priorities, administrative barriers, and lack of time for faculty and coordinators . To overHere we aim to describe findings from an ISPCTN pediatric research capacity inventory and to highlight the parallel development of a professional development curriculum, as well as qualitative reports of site-specific learning activities aimed at enhancing pediatric research capacity. Three primary capacity domains are presented: faculty/coordinator development, enhancement and expansion of organization-institutional infrastructure, and clinical trials/research concept development.In the 1st year of ISPCTN, each awardee site principal investigator and affiliated sites were sent a REDCap site assessment inventory, developed by the Data Coordinating and Operations Center, in December 2016 . The inventory was completed by each site and affiliated site(s) prior to Network trial initiation. The domains of the inventory sought to identify and describe existing infrastructure and was used as a tool to inform the overall capacity building needs of the Network prior to trial initiation, thus did not meet the 45 CRF 46 definition of research. The inventory consisted of 57 multiple-choice and open-ended questions.Inventory domains and description of content questions are outlined in Other site capacities were inventoried. These included a human subjects review domain that ascertained information regarding regularity of Institutional Review Board (IRB) meetings and possible obstacles to timely reviews. The study monitoring domain collected site information including location of source documents stored in medical records and the ability to accommodate monitor visits, including work space and access to medical record (paper/electronic). The laboratory domain assessed site access to a local laboratory for specimen processing and dedicated equipment . Sites were also assessed for imaging capabilities, including the availability of pediatric facilities for X-ray and MRI.Facilities questions elicited information on infrastructure available for research, including neonatal intensive care unit (NICU) presence at the site, dedicated pediatric research space, investigational pharmacy, storage for lab supplies, practice management system, and medical records. Information was obtained on electronic/mobile health communication and if sites were tracking mobile device usage in their patient community. The data management domain included the availability of EHR resources.Professional development curriculum and site-developed training modules were created by the DCOC. The professional development curriculum was comprised of learning themes . These wOverall, 17 ISPCTN sites and 7 affiliates are predominantly at academic medical centers , with sites also including Tribal health organizations and primary care centers.n = 24) reporting previous experience with clinical trials] in ECHO disease priority domains; with 17 of 24 principal investigators reporting participation in a clinical trials network. However, variability was observed. ECHO domains with the greatest site investigator trial expertise were perinatal outcomes (n = 17), obesity (n = 17), and airway diseases (n = 18) . Less trial experience was observed in positive child health and neurodevelopment . Among study coordinators, less trial experience in ECHO domains was reported [38–42% (n = 9–10) with previous experience].All ISPCTN site principal investigators reported having clinical trials expertise . However, research pharmacy capacity for investigational agents was reported at fewer sites . Infrastructure for biosample storage and shipping, research refrigerator and freezer availability, and refrigerated centrifuges were frequently reported [92–96% (n = 22–23) of sites].Most ISPCTN sites had facilities critical to implementation of pediatric trials. NICUs were identified at 79% , with EPIC and Cerner being the most common (22 of 30 sites and subsites) of those using electronic medical records.n = 18 of 24), though text messaging is less often used . However, across all sites, the estimated percent of patients with an email address was 60% (median). A high level of enthusiasm was evident for using e-communication for collection of research data [96% (n = 23) of sites expressing interest in this modality], though relatively few actively collect information on patient mobile capabilities .Patient communication through email occurs at many sites , other necessary physical attributes , and site training needs. Imperative in the inventory findings, we find three necessary elements that are of greatest importance: (a) having site leadership with trial experience; (b) providing skills-focused training for investigators and coordinators; and (c) supporting site infrastructure, such as protected time for development and conduct of trials. Our inventory provided the Network with simple metrics about sites and identified several areas where variability was evident . An inventory approach to determining site and Network capacity for clinical trials has not been evident in the extant literature on capacity building, thus the current presentation fills a gap in providing domains and context that may be a useful startup activity for new research teams and new networks. For the ISPCTN, the inventory findings were disseminated to sites in two ways: a document was developed and disseminated, and findings shared/discussed at a steering committee meeting. This approach was intended to motivate site teams to action that would facilitate the successful conduct of trials through active support and engagement in Network trials.In the initial year of funding sites were invited to share and build upon tools and activities established, as well as draw upon and contribute to the centralized activities provided by the DCOC. The ability for sites to augment Network knowledge as a whole, and for the Network to augment the capacity of sites, was a crucial element of the capacity building approach adopted. Best practices were identified and shared, exemplifying the bi-directional commitment to accelerating pediatric trial capacity development. The ISPCTN was thus built upon existing site capacities for pediatric trials research, which could be more rapidly advanced together, while developing research capacity and Network culture, essential for successful implementation of multi-site pediatric trials.From the assessment inventory and curriculum development, several important lessons stand out.Educational opportunities provided by a central coordinating center, such as online training modules, provides an efficient, effective mechanism for engaging multiple sites, establishing shared operating procedures, and providing uniform knowledge for pediatric trials. Sites within the Network brought a range of individual and institutional expertise, from those sites where individuals had limited trials research knowledge and limited staff expertise, to those that had participated in networked trial groups . Institutional resources for research have been supported by the ISPCTN, serving as a stimulus to support the development of pediatrician scientists. Centralized training has facilitated the development of common trials knowledge for pediatric faculty and staff. Module utilization suggests several training topics received generally greater participation , indicating training gaps that were not necessarily anticipated. The modules have provided a foundation that is being further built upon with the implementation of network trials and associated trial-specific trainings. We anticipate that both individual and institutional trials expertise will continue to develop as a range of pediatric trials are opened across the Network. Pediatric academic research training is a continuous and career long endeavor that needs to constantly be updated through professional development activities, which the ISPCTN recognizes and is addressing.Characterizing infrastructure prior to the initiation of pediatric clinical trials provides necessary information, yet alone is insufficient for operationalizing trials for children in rural and medically underserved communities. This is particularly true across a network that have diverse pediatric health issues that are the focus for trials. The inventory findings suggest the need for teams with less trials research background or for those who have not received training in clinical trials need to be provided with learning opportunities that increase research skills necessary for successful trial completion. Missing in our inventory, however, was a clearer characterization of site leaders' experiences with different types of trials . While multi-site trials experience is clearly essential and important for building capacity, it is also heterogeneous, and opportunities for scholarly productivity from some trials may be limited to more seasoned investigators.Capacity building for pediatrician scientists and coordinators must include a determination of local resources and barriers to research. Barriers may include (a) protected research time in order to establish and develop pediatrician scientists and (b) implementation of pediatric trials within rural and medically underserved communities. While this presentation addresses network capacity and development from that perspective, the ability to establish a research culture within a site and within rural communities is an important element of sustainability. Local institutions and departments developing new programs may identify administrative challenges, such as developing grant budgets and contracts. Departmental priorities for clinical productivity and teaching, as well as balancing professional commitments, can have an impact upon scholarly productivity. Similarly, building sustained relationships with underserved communities requires identification of community champions and the development of trusting relationships between investigators and community members. These and other factors  will be important to assess in future capacity assessment inventories, as they play an indirect, but instrumental role in the success of the network.Network capacity rests upon the sites that can successfully operationalize pediatric trials while embracing principals that support research accomplishments . Findingneeds assessments of individual sites and individual investigator research needs. Rather than an inventory, a needs assessment encompassing early career, senior faculty, and coordinators could provide greater depth of appreciation of gaps within and across sites. Additionally, sites did not provide their full educational and training materials, but may have provided topics that were unique or demonstrated a particular area of interest, and were not meant to be comprehensive of their full curricula.Research capacity building for multi-site pediatric clinical trials has been inadequately described in the literature. While our presentation serves to increase available information, there are several shortcomings with our approach. First, our approach identified research infrastructure capacities across sites, yet did not specifically focus on pediatric research Identifying features of ISPCTN site has been a remarkable adjunct to the competence areas that are needed in a multi-site network. Professional development has only recently been identified as a competency area in pediatrics . PediatrDescriptions of the implementation of trials networks have typically focused upon developing network priorities and research agendas –32, yet The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.RA, AK, CT, and AA were responsible of the conceptualization and design of the manuscript contents, as well as the interpretation of data. RA drafted the initial version of the manuscript. SB, JC, KC, SC, MF, JJ, AK, JK, KK, AL, PM, MM, LPa, BP, LPy, JSh, KS, JSn, CT, and AA revised and edited the manuscript. All authors approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Ending preventable maternal and newborn deaths and disabilities remains a key global priority, central to achieving a healthier, more just and equitable world, as highlighted in the Sustainable Development Goals Every Newborn Action Plan (ENAP) [Over two million newborns die each year and newborn deaths account for 47% of deaths among children under five globally. Most of these deaths are preventable n (ENAP) , a globaGlobal Strategy for Women's, Children's and Adolescents’ Health (2016 – 2030) High quality health systems could save over eight million lives per year in low- and middle-income countries (LMIC) Antenatal care represents an important opportunity for reaching women, preventing, diagnosing and/or treating maternal and perinatal conditions and, potentially, for improving health outcomes Ensuring progress in maternal and newborn health and well-being necessitates addressing both supply-side and demand-side barriers and facilitators. Essential and life-saving services need to be available, accessible, acceptable and of high quality National Essential Public Health Program.By evaluating a pilot program designed to integrate prenatal screening interventions for congenital abnormalities into routine antenatal care in western rural China, Xin Ling Feng and Chunmei Wen The Lancet Regional Health – Western Pacific, provide valuable evidence from the clinical research perspective on the effectiveness of China's two interventions: providing free prenatal foetal aneuploidies screening and prenatal B-ultrasound screening. Findings from this research support the country's efforts of integrating screening for congenital abnormalities into routine antenatal care, and contributes to the National Essential Public Health Program, which is currently rolling out throughout the country.With congenital anomalies contributing to 10.8% of China's burden of neonatal mortality, the results of this study, published in Results of the research indicate that the coverage of prenatal fetal aneuploidies and B-ultrasound screening rose by over 20 percent. “Supply-side policies” appeared to be more effective for women with secondary education and above, while “demand-side policies” appeared more effective for women with primary education and below and those from remote mountainous areas.The study involved some limitations. Causal conclusions cannot be made, due to the study design  as well as potential sources of bias , although adjustment was made for demographic and socio-economic factors, to reduce bias. Additionally, the research examined topology/geography ; however, other factors could be relevant to women's access to antenatal care services, such as public transportation availability and road conditions. Furthermore, Ningxia is an autonomous region inhabited by Hui minority groups. Culture and ethnicity issues could potentially impact service coverage when comparing the counties. Furthermore, the research would be strengthened if discussion on the coverage rate of prenatal care for the disadvantaged population (e.g. “floating population”) were included, together with recommendations on policies and programs. Finally, the study did not assess the health impact of this initiative.Nevertheless, this study makes an important contribution by bridging clinical medicine with policies and interventions. It contributes to the evidence base on delivering integrated maternal/newborn health services in China. With congenital anomalies contributing to over 10% of neonatal mortality nationally, it addresses an important public health issue in China. The study helps fill the evidence gap regarding coverage and equity of prenatal screening in rural China, as well as the role of demand-side financing. Furthermore, the research offers insight into the variable impacts of interventions on different population groups.Additional research to assess the impact of such initiatives on newborn and child survival and health in remote/rural/underserved settings similar to those of rural western China, is recommended. Linking the increase of antenatal care and integrating congenital anomaly screening with the effects on newborn's/children's health using temporal collected data would be more powerful to provide evidenced-based results to decision makers and health professionals. Including key questions in the follow-up routine collected data is recommended for future work.We declare no competing interests.


To describe the INTERASPIRE scientific protocol—an international survey of secondary prevention of coronary heart disease (CHD).This international survey is being conducted through National Societies of Cardiology in selected countries from each of the six WHO regions and has the following overall aims: (i) describe prevalence of cardiometabolic and renal risk factors together with biomarkers in CHD patients; (ii) describe current risk factor management through lifestyle changes and cardioprotective drug therapies; (iii) provide an objective assessment of clinical implementation of preventive care by comparison with the lifestyle and risk factor targets defined in international and national guidelines; (iv) investigate the reasons for variation in preventive cardiology practice between regions and countries; and (v) promote the principles of best preventive cardiology practice.This international survey will provide a unique picture of CHD patients; their cardiometabolic, renal and biomarker status; lifestyle and therapeutic management; and the quality of preventive care provided in all WHO regions. The main objectives of cardiovascular (CVD) prevention are to reduce cardiovascular morbidity and mortality, improve quality of life and increase life expectancy. The 52-country INTERHEART study has shown that the classical risk factors for coronary heart disease (CHD) account for most of the risk of MI worldwide . TherefoThere is a wealth of scientific evidence supporting interventions in relation to lifestyle ; the treatment of obesity, hypertension, dyslipidaemia and diabetes; and the selective use of prophylactic drug therapies. All these interventions can reduce cardiovascular morbidity and mortality in those with established atherosclerotic disease and can also reduce the risk of developing atherosclerotic disease.This scientific evidence informs international, regional and national guidelines on CVD prevention, which define patient priorities for preventive action and lifestyle and treatment goals •, 7–9. AGuideline implementation in Europe has been evaluated in five cross-sectional surveys called EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events). The first survey was in 1995–1996, and this was followed by the second, third, fourth and fifth surveys in 1999–2000, 2006–2007, 2012–2014 and 2016–2018, respectively, through the European Society of Cardiology (ESC) Euro Heart Survey/EuroObservational Research Programme –12. The The INTERASPIRE survey began when the ESC EuroObservational Research Programme decided to expand the EUROASPIRE programme to include other WHO regions, starting with a pilot study in Malaysia and Argentina in 2019. The main survey (2020–2022) is now being organised in partnership with the World Heart Federation, Asia Pacific Society of Cardiology, InterAmerican Society of Cardiology and the Pan-African Society of Cardiology and includes selected countries in all 6 WHO regions: African Region, Region of Americas, Eastern Mediterranean Region, European Region, South-East Asia Region, and Western Pacific Region.To determine in patients with established CHD (acute coronary syndrome or revascularisation by angioplasty or coronary artery surgery) whether guidelines on cardiovascular disease prevention and rehabilitation are being followedTo compare diagnostic and therapeutic strategies in patients with established CHD in relation to glucose metabolism To compare diagnostic and therapeutic strategies together with risk prediction models for atrial fibrillation in patients with established CHDTo compare diagnostic and therapeutic strategies in prevalent cases of familial hypercholesterolaemia in patients with established CHD and the residual risk among these patients with current treatmentsTo compare diagnostic and therapeutic strategies in patients with established CHD in relation to chronic kidney disease (CKD)To describe the prevalence of cardiovascular risk factors, acute and long-term cardiovascular complications and therapeutic management in patients with CHD with and without exposure to COVID-19To measure new cardiovascular biomarkers to quantify residual risk and describe relationships with lifestyle, traditional risk factors and therapeutics and how these biomarkers impact outcomesTo follow-up all CHD patients 1 year after the interview for hospitalisations, cardiovascular procedures, cardiovascular events and cardiovascular and all-cause mortality and relate management to outcomesTo identify strategies for improving preventive care of CHD patients based on the INTERASPIRE survey results and make policy recommendations through WHF, continental and national societies of cardiology to WHO and national governmentsThe specific objectives of the INTERASPIRE survey are:An international survey of CHD patients is being conducted in selected countries from each of the six WHO regions around the world.In selected geographical regions within each country, and selected public hospitals, a consecutive sample of patients admitted with CHD is being identified retrospectively and information on their management recorded from their hospital medical record, including drugs on discharge. , fasting glucose, HbA1c, creatinine and cardiovascular biomarkers. Patients without a self-reported diagnosis of diabetes mellitus have an oral glucose tolerance test. All patients have urinary creatinine/albumin ratio measured in local laboratories.All coronary patients are then followed up 1 year after interview for hospitalisations and cause specific and all-cause mortality.African RegionKenya (Kenyan Cardiac Society)Nigeria (Nigerian Cardiac Society)Regions of AmericasArgentina (Argentine Society of Cardiology)Colombia (Colombian Society of Cardiology and Cardiovascular Surgery)USA (American College of Cardiology)Eastern Mediterranean RegionEgypt (Egyptian Society of Cardiology)Qatar (Gulf Heart Association-Qatar)United Arab Emirates (Emirates Cardiac Society)European RegionPoland (Polish Cardiac Society)Portugal (Portuguese Society of Cardiology)Russia South-East Asia RegionIndonesia (Indonesian Heart Association)Malaysia Philippines (Philippine Heart Association)Singapore (Singapore Heart Foundation/Singapore Cardiac Society)Western Pacific RegionAustralia China (Chinese Cardiovascular Association)WHO regions, selected countries and National Societies of Cardiology:Within each country, at least three geographical areas are selected and all hospitals serving those populations identified. The areas include at least one hospital offering interventional cardiology and cardiac surgery and one or more acute hospitals receiving patients with an acute coronary syndrome. Hospitals are selected in each geographical area in such a way that any patient presenting within the area with acute symptoms of CHD, or requiring revascularisation in the form of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), has an approximately equal chance of being included in the patient sample.Elective CABG.Elective PCI.Acute coronary syndromes (acute MI with ST elevation (STEMI) and Non-ST elevation MI (Non-STEMI) including those treated with primary PCI and/or CABG and unstable angina).Within each hospital, consecutive patients, men or women [≥18 years and <80 years at the time of identification], with first or recurrent clinical diagnosis or treatments for CHD (see below) are identified retrospectively from diagnostic registers, hospital discharge lists or similar sources between 6 months and 2 years before the expected date of interview. Patients may fulfil more than one of the following diagnostic criteria:It is recognised that hospital diagnoses for acute MI, and unstable angina without evidence of infarction, may not always meet the World Health Organization (WHO) or other standard diagnostic criteria. However, it is important to include all cases diagnosed in each hospital as acute MI or unstable angina because, as a consequence of these diagnoses, they should have all received appropriate management for secondary prevention.In order to achieve an interview response rate of at least 60%, a sufficient number of patients with CHD (approximately 660) are identified across all hospital sites to give a total sample of 400 interviewed coronary patients in each country.https://moodle.org/). All other countries are now being trained using this online facility. All study documentation, manuals and training videos can be accessed on this platform.Training of data collectors from the pilot countries  was conducted in person at the National Society headquarters by the coordinating team from NIPC. Following the advent of the COVID-19 pandemic in early 2020, the coordinating centre developed an online training platform using an open-source learning platform Diagnostic procedures undertaken (or scheduled): coronary angiography, echocardiography or other imaging modalities, exercise or pharmacological stress testsMeasurements of weight, height, body mass index and waist circumferencePresence of tendon xanthomata and corneal arcusMeasurement of blood pressureBlood tests: lipids , fasting/random plasma glucose, HbA1c, OGTT, eGFR/ serum creatinineRhythm recorded on 12 lead ECGUrine albumin/creatinine ratioMedication  including antiviral and other medications being studied for COVID-19 and detail on ACEI/ARBsThe following information is obtained from the medical records both prior to and following the date of acute index hospital admission or procedure:Personal and demographic detailsPersonal cardiovascular history, including stroke, TIA (transient ischaemic attack), PAD , heart failure, valvular heart disease and age at which disease was first manifestOther medical history, including hypertension, hyperlipidaemia, glucose metabolism and COVID-19 infectionFamily history of CHD for patients with premature disease (men < 55 years and women < 60 years) in first-degree relativesReported lifestyle and other risk factor management in relation to smoking, diet (including weight reduction), alcohol, exercise, blood pressure, lipids and glucose and reported referral to and attendance at cardiac rehabilitation programsMedication  including detail on ACEI/ARBsLevel of education, school attendance and employment statusThe following information is obtained at least 6 months and at most 2 years after the acute index admission or procedure:Height , weight  and waist circumference + Smokerlyzer)Breath carbon monoxide  automatic digital sphygmomanometer)A digitised 12-lead electrocardiogramA cardiac ultrasound examination report from the medical recordVenous blood processed for serum and plasma and stored at −80° at a country level and then transported on dry ice to the Central Laboratory in Helsinki to measure total cholesterol, HDL cholesterol, triglycerides, calculated LDL cholesterol, creatinine, HbA1c, COVID antibodies  and biomarkers: high-sensitivity Troponin I, brain natriuretic peptide (BNP), NT-pro-BNP, galectin-3 and potentially soluble urokinase-type plasminogen activator receptor (SuPAR)Local laboratory measurements of fasting glucose, 2-h post glucose load in an OGTT and urine for albumin/creatinine ratioLong-term storage of blood: serum, plasma and whole blood for HbA1cSelf-administered questionnaires: HADS , HeartQoL , EuroQoL  and Medication Adherence QuestionnaireThe following examination and measurements are made:Vital status: alive/dead or unknownCause of death: CHD, stroke, other vascular, cancer, other cause, unknownProcedures or events performed since the date of interview:Hospitalisation for: PCI, CABG, AMI, stroke or TIA, heart failureDiagnosed with diabetes mellitus: yes, no, unknownFollow-up will be conducted at 1 year following the date of interview for vital status and procedures or events as listed below:Web-based data entry will be used at all sites and data management will be undertaken by the EURObservational Research Programme Department  at the European Heart House, Sophia Antipolis, Nice, France, for the pilot study in Argentina and Malaysia and by AIMES Management Services Limited  Liverpool, UK, for the main study.Central laboratory analysis of whole blood HbA1c, serum total cholesterol, HDL cholesterol, triglycerides and creatinine as well as fasting plasma glucose is undertaken in all coronary patients together with COVID-19 antibodies and cardiovascular biomarkers. OGTT from plasma and albumin/creatinine ratio from urine are analysed at each hospital site. Whole blood, serum and plasma are frozen locally and transferred to the central laboratory for biochemical analysis and long-term storage.In order to estimate prevalences with precision, a sample of 400 coronary patients attending interview is sufficient to estimate within-country prevalences with a precision of at least 5% and a confidence of 95%. The precision of estimates after stratification for age and gender within a country are limited but combining data from all countries will allow precise estimates by age and gender.All the patients enrolled are included in the analyses. Since this is an observational study, descriptive summaries will be presented for all the patients and for subgroups of patients to report the prevalence of risk factor recording and management within and between countries. Statistical tests may be carried out for exploratory purposes, as appropriate. Multivariable analyses may be used to explore relationships between baseline covariates and post-baseline endpoints, as appropriate.+ Smokerlyzer)Smoking habit  Physical activity Height and weight Waist circumference Body mass index (BMI)Overweight/obesityDiabetes (self-reported) and new diabetes, impaired fasting glycaemia and impaired glucose tolerance  and HbA1cBlood pressure will be measured twice in a sitting position on the right upper arm and the mean of the two measurements will be used in the data analyses. (Omron M6 (HEM 7211-E) automatic digital sphygmomanometer)Serum total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, calculated low-density lipoprotein (LDL) cholesterol), serum creatinine, plasma glucose, HbA1c, COVID-19 antibodies and biomarkers: high-sensitivity Troponin I, brain natriuretic peptide (BNP), NT-pro-BNP, galectin-3 and potentially soluble urokinase-type plasminogen activator receptor (SuPAR)Variables for the Dutch Lipid Clinic Network criteria to estimate the probability of FH, including personal/family history/laboratory measurements/physical examination and presence or absence of a molecular diagnosisAtrial fibrillationUrine for albumin/creatinine ratioAntithromboticsBeta-blockersACE inhibitorsAngiotensin-II receptor antagonistsLipid-lowering drugsHypoglycaemic treatmentsDiureticsCalcium channel blockersNitratesIf inhibitorsMetabolic agentsNicotine replacement therapyBupropion hydrochlorideVareniclineAntiobesity drugsAntidepressantsAntianxiety drugsDrug therapies:Psycho-social measures The main outcomes of interest include the proportions of hospital coronary patients achieving lifestyle, risk factors and therapeutic targets for cardiovascular disease prevention. The management of risk in terms of lifestyle intervention and the use of drug therapies will be evaluated in relation to the lifestyle and therapeutic goals defined in the guidelines on cardiovascular disease prevention:Finally, we will ascertain 1-year outcomes, specifically cardiovascular events , and cardiovascular/total mortalityThis international survey of secondary prevention of CHD patients in selected countries across all WHO regions will provide an in-depth analysis of lifestyle, risk factor and therapeutic management within, and between, countries and regions in relation to international and national cardiovascular prevention guidelines. The arrival of the COVID-19 pandemic led to a rapid change to the scientific protocol to capture exposure to this new virus, by measuring antibodies, which can then be related to subsequent cardiovascular outcomes. The results of this survey will be made available to the World Heart Federation Global Observatory, and also to National Societies of Cardiology, to inform advocacy to policy makers in WHO and national governments to raise standards of preventive cardiology.


Many challenges exist in providing equitable access to rural healthcare in the Democratic Republic of the Congo (DRC). WHO recommends student exposure to rural clinical rotations to promote interest in rural healthcare. Challenges to rural engagement include lack of adequate infrastructure and staff to lead rural education. This case report highlights key steps in developing a rural rotation program for DRC nursing students.Case presentationTo implement a rural rotation (RR) program, ICAP at Columbia University (ICAP) consulted with students, the Ministries of Health (MoH) and Education (MoE), and nursing schools to pilot and expand a rural rotation program. Nursing schools agreed to place students in rural clinics and communities. Key stakeholders collaborated to assess and select rural sites based on availability of nursing mentors, educational resources, security, accessibility, and patient volume. To support this, 85 preceptors from 55 target schools and 30 rural health facilities were trained of which 30 were selected to be “master trainers”. These master trainers led the remaining 55 preceptors implementing the rural rotation program. We worked with rural facilities to engage community leaders and secure accommodation for students.A total of 583 students from five Lubumbashi schools and two rural schools outside Kinshasa participated across 16 rural sites (298 students in 2018–2019 school year and 285 in 2019–2020). Feedback from 274 students and 25 preceptors and nursing school leaders was positive with many students actively seeking rural assignments upon graduation. For example, 97% agreed or strongly agreed that their RR programs had strengthened their educational experience. Key challenges, however, were long-term financial support (35%) for rural rotations, adequate student housing (30%) and advocacy for expanding the rural workforce.With nearly 600 participants, this project showed that a RR program is feasible and acceptable in resource-limited settings yet availability of ample student accommodation and increasing availability of rural jobs remain health system challenges. Using a multipronged approach to rural health investment as outlined by WHO over two decades ago remains essential. Attracting future nurses to rural health is necessary but not sufficient to achieve equitable health workforce distribution. This case study presents a novel rural rotation (RR) program in rural Haut Katanga province of the Democratic Republic of the Congo (DRC). Health systems continue to grapple with how to ensure a robust rural health workforce despite long-standing WHO recommendations on rural education, regulation, financing, and support as key measures to improve health equity . In DRC,DRC, a country with a historically high burden of disease, political instability and low health system use, gained independence in 1997 and has received United States President’s Emergency Plan for AIDS Relief (PEPFAR) funding since 2003 . DRC is The DRC health system is divided into three major levels including the central level led by the Ministry of Health, the intermediate level—including provincial health hospitals and oversight of programs at the level of health zones. The intermediate level, while maintaining a degree of decentralized control in health service inspection and implementation remains beholden to national policies and directives. Most preventive and curative care is provided through over 500 health zones, 300 general reference hospitals and over 8000 health centers. Health centers are staffed by five-member team led by an advanced level (A1) and secondary level (A 2) trained nurse. A laboratorian, receptionist and logistics/maintenance staff member round out the rural team.Maldistribution of health workers continues to challenge achievement of universal health coverage and the Sustainable Development Goals (SDGs). Improving access to care is essential to achievement of the SDGs, particularly SDG 3  and 10  United Nations . Nurses,The DRC health system is also tasked to respond to a generalized HIV epidemic with an estimated prevalence of 1.2% among adults aged 15 to 49. An estimated 404,894 people are living with HIV, and around 10,535 people die from AIDS-related conditions each year [ICAP at Columbia University (ICAP) initiated a comprehensive program of support for HIV care and treatment (C&T) services in DRC in 2010. Since then, ICAP has worked hand-in-hand with the Programme National de Lutte contre le SIDA (PNLS) to expand availability, quality, and uptake of adult and pediatric HIV care and treatment in DRC with an emphasis on expanding prevention of mother-to-child transmission (PMTCT) activities, building laboratory networks for disease monitoring, integration of HIV and tuberculosis (TB) services, improvement of infrastructure, prevention among key populations (KP) in Kinshasa and Haut Katanga provinces. The program has expanded from 10 sites in 2010 to 240 public and private hospitals, health centers, and TB clinics as of September 2014. ICAP currently supports the health ministry in 199 sites.With PEPFAR funding through the United States Health Resources and Services Agency (HRSA), in 2017, ICAP was awarded the Resilient and Responsive Health Systems (RRHS) project to continue strengthening HRH in DRC. Using the World Health Organization (WHO) conceptual framework for HRH development, the first 2 years of the RRHS project built on extensive HRH capacity-building and infrastructure improvements for student nurses and midwives through the HRSA-funded Nursing Education Partnership Initiative (NEPI) and Global Nursing Capacity Building Program (GNCBP) , 12. NEPGiven the volume of people living in rural areas and HIV service needs therein, a collaborative effort between the MoH, Ministry of Education (MoE), ICAP and HRSA has yielded a RR program to increase nursing student and community health worker (CHW) exposure to rural health needs as well as rural clinical practice and community engagement prior to graduation, entry to practice, and employment. Additional strategies, not presented here, included the development of a telementoring program to bridge rural health centers with urban specialists and trainers as well as assistance with national registration of nurses.An increase in the use of telemedicine globally has expanded access to quality healthcare services regardless of a patient’s proximity to physical medical care/clinic services , 14, dimAn interesting healthcare paradox exists in rural settings, compared to urban ones, no matter where one looks in the world: rural communities in which some of the most numerous, complex, and diverse healthcare needs exist are precisely those served least by HRH. Despite the prevalence of unmet rural healthcare needs, healthcare providers tend to remain in wealthier, better resourced, urban areas . A retroThese inequities, alone, however, are not the only reasons for higher incidence and prevalence of some infectious diseases , malnutrition, and less preventative care in rural areas. Social determinants of health also come into play including access to education, food and social support . Given sRural determinants of health result in relatively lower health indicators and indices; for example: greater numbers of stillbirths and higher infant mortality in Central Africa , greaterFailure to address rural healthcare staffing and care provision leads to underreporting of diseases, such as Buruli ulcer in DRC , lack ofIn 2019 with support from HRSA, ICAP launched a telementoring program in DRC to help address some of disparities and lack of knowledge transfer from urban to rural settings . While sEngaging students in rural contexts while increasing their familiarity and understanding of rural health needs allows students to experience the breadth of health services provided in rural areas and opportunities to expand knowledge and skills. Under the mentorship and supervision of experienced rural clinicians, students are exposed to a broader array of healthcare challenges than may be seen in urban settings where care is divided between many units and specialized services. This level of exposure to health issues, symptomatology, and engagement in all aspects of care from health history, point of care laboratory investigations, diagnosis and follow up can rapidly build clinical competence. Students live in and absorb more varied cultural environs and may establish early career leadership and managerial success on a scale more demonstrable than in urban settings where one is “lost in the crowd” of the larger healthcare workforce. Exposing nursing students to the opportunities in rural setting scan create more HRH who are willing to work in rural settings after graduating .This case study describes the preparation phase and 2 years of implementing a RR program. The preparatory phase including three distinct, sequential yet complementary activities including stakeholder engagement, practicum planning (with nursing schools) and clinic preparation .Train students to be future health workers on a global scale.Prepare them to work in all conditions, even in the remote environments both in hospitals and in rural communities.During the alignment phase of the project, ICAP/RRHS conducted meetings with the DRC MoH, MoE, Nursing Council, Midwife Association, target schools, students, and students’ parents to raise awareness of the subject by explaining to them the requirements of Education Reform using a competency-based approach:Once consensus was reached with key stakeholders on key competency goals, the joint ICAP/RRHS team partnered with nursing schools to support the RR launch.Once key stakeholders understood the value of building rural practice core competencies in nursing students, getting the nursing schools, themselves, on board was a critical next step. Collaborating to define how the program would be implemented, how progress would be measured, which sites would use, and what safety and security guarantees would be needed were crucial consideration during the planning phase. Once these discussions took place and nursing schools agreed to the RR plan, the team had to identify clinics that were willing to receive nursing students on short-term, rural rotations followed by post-rotation debriefings and continued coursework.Mapping of rural sitesTo start, DRC MoH and MoE, working in conjunction with ICAP, identified specific rural sites most likely to be able to handle an influx of students. The ministries informed selected sites and set expectations for the rotational program.Assessment of rural sitesNext, a joint MoH/ICAP team conducted site visits to assess conditions and readiness of the target clinics to receive students. A MOH senior nurse and clinician in charge of health zone technical support, as well as a policy and training manager, and a monitoring and evaluation specialist from ICAP, visited each site and conducted surveys of living and teaching conditions. Site-level assessments focused on four key areas:Availability of clinical and teaching materials and equipment (including pathologies)Accessibility, security, and accommodationHealth center volumeQuality and number of health workers including availability of preceptors.A detailed site assessment tool was developed to facilitate site-level collaboration and assessment see Fig. .Training of preceptorsAfter completing site-level assessments, preceptors from schools and rural facilities were identified for training by the MoH and MoE with ICAP/RRHS technical assistance. Preceptor training focused on how to mentor and train student nurses using a competency framework. To drive efficiency in the training of preceptors, a training of trainers’ approach was used whereby the experts and technical assistants selected a subset of preceptors to complete detailed training. These “master trainers” then trained the remaining preceptors at the various sites. Key topics and competencies covered are presented in Fig. Preparing to receive students at different clinic sites took considerable time and energy including site-level assessment, preparation, and education. Sites were assessed for readiness to accommodate students , availability of space in which students could live, learn and practice, availability and quality of preceptors to monitor and evaluate their learning, and broader community acceptance of an influx of student nurses and healthcare provision by nursing students.Concurrently, MoH, MoE and ICAP continued to align with target clinics to obtain buy-in to the RR program educational aims, objectives and how the program could help to address persistent HRH challenges. Program staff met with community leaders, religious leaders, local authorities, and elders, to explain the program, obtain community feedback and to practically identify accommodations for nursing students. Community engagement was an important step in community acceptance; to preempt/mitigate challenges which could arise from nursing students rotating in and out of their communities.Following assessment of the rural sites, 85 preceptors from 55 target schools and 30 rural health facilities were chosen to be trained as preceptors. Of the total 85 preceptors, 30 individuals completed detailed training with the experts from the MoH and MoE. The 30 individuals were then considered “master trainers” who then trained the remaining 55 preceptors at various sites. As of May 2020, the 30 master trainers have on-boarded an additional 263 preceptors to improve nurse mentorship and instruction during students’ rotations.All five targeted schools in Lubumbashi participated in the RR program. The DRC urban capital, Kinshasa, was not targeted for RR programs, but two schools supported under NEPI expressed interest and accepted rotating nursing students .ISTM Lubumbashi: 141 nursing studentsIEM Kamalondo: 54ITM Immaculée Conception: 65ITM Zaidi: 38Sixteen sites took part in the RR program. In the 2018–2019 academic year rotations lasted 1 month for secondary level nurses and 3 months for advanced nurses. Participation by nursing schools were broken out as follows:ISTM Lubumbashi (February–July 2020): 87 nursing studentsIEM Kamalondo (February–March 2020): 72ITM Immaculée Conception (March 2020): 81ITM Zaidi (February–March 2020): 45In the 2019–2020 academic year, participation, delayed before of COVID-19 has thus far comprised:Nursing student experienced a wide variety of rural healthcare services including patient care, and community engagement. Students attended to patients during clinic hours and established themselves as valuable community members through outreach , preventative health advocacy , and as role models for future nursing students and CHWs.After completing their RRs, students provided voluntary feedback to inform and improve RRs. 274 students, as well as 25 preceptors and nursing school leaders, provided feedback , housing (30%), and rural living conditions (3%). Levels of responsibility and preceptor support were also reported by a few respondents see Fig. d. The ICThis 2-year case study demonstrates that a RR program is feasible in low-resource settings. Complementary efforts to register rural nurses and increase access to the latest information and specialist support through telementoring were simultaneously introduced and scaled up. Systematic preparation, stakeholder engagement, site assessment and training of preceptors were critical steps to the program’s early success. Collaboration, a detailed rotational schedule, and developing accommodation for students and preceptors were keys to success.Student feedback indicates increased opportunities to engage patients and to take part in community-based programs such as home visits, behavior change education, community awareness and health promotion. These activities enhance student exposure and experience in the breadth and depth of primary and acute clinical care. Nursing school leaders and clinic managers reported student engagement to be an asset rather than a burden given the paucity of health workers available in rural settings.Through donor support, ICAP has supported minor renovations at all 16 sites to improve accommodation conditions and assistance for student and preceptor transportation. In the first year of RR implementation, students were placed at all 16 sites. However, in the second year of placements, only 15 of the 16 sites were staffed due to security issues at one of the sites. The renovations completed on the living quarters for nursing students ensured students would have a secure rural residence. As sustainability is a key goal of this program, ICAP has worked with HRSA, MoH, and MoE to develop a transition and sustainability plan.Specifically, the programs School Sustainability Plan includes ensuring ongoing maintenance of living accommodations for nurses, continued transportation support, and longitudinal tracking of key educational outcomes to demonstrate program success . By seeing this value from the RR program, continued funding and support has been secured for the foreseeable future. With the onset of COVID-19 and evolving healthcare priorities, rotating nursing students have been uniquely positioned to provide immediate frontline support. As such, DRC MoH and MoE have realized even more value from this program than originally envisioned and have committed to continued funding of RR activities like these in the future.Key challenges to initial launch and ongoing operation of the RR program revolved mostly around accommodation availability and student financial assistance. Not all sites provided accommodations for student nurses, and at those where accommodations were available, spaces were poorly maintained and in need of renovation. Some nursing students also faced financial difficulties including support for transport to rural clinic sites. While the ICAP team was successful in securing some MoH/MoE funding/resources to support students’ needs, these challenges must continue to be addressed to ensure long-term viability of such a program.This case study has focused on building a nursing RR program recognizing the centrality of nurses to improving access to care. It has shown that a RR program is both acceptable and feasible in remote areas of DRC. Strong support from students, local staff, educators, and health administrators is evident. Broad stakeholder engagement and capacity-building are keys to this success and eventual transition to local ownership and sustainability. Early positive results have been presented using qualitative data and quantitative results to the outcome level. Further study of the essential components as well as short- and longer-term benefits and sustainability of a rural rotation program is encouraged. Further study of the impact of such a program on the recruitment and retention of rural health workers following a rural rotation program as well as the impact of access to health care and health care outcomes is urgently needed. Yet this cannot occur in a vacuum. Using a multipronged approach to drive full implementation of recommended policies and measures to safeguard health workers are required , 8. IdenWhile the literature clearly shows that exposing students to rural practice is an important strategy to improve interest in and appreciation for rural care  and a ru


The COVID-19 Pandemic has led to significant morbidity and mortality in older residents of long-term care facilities. In addition, the stringent restrictions on visitation of family and loved ones has further socially isolated residents leading to an increase in depression, loneliness, and spiritual distress. The Community Living Center (CLC) staff at West Palm Beach VA Medical Center wanted to address this dilemma and created a unique “Butterfly Garden” (BG) visitation space. This space is a therapeutic garden adjacent to the CLC that can be accessed by families without having to enter the facility. Participants in the BG reported feelings of peace, undisturbed reflection, and tranquility as they observed and experienced nature’s life cycle. This show of nature’s beauty promotes visual, tactile, and olfactory sensory stimulation while attracting hummingbirds, bees, butterflies, and peace to this calm garden space. The BG visitations offers residents, family, and staff opportunities to experience the health benefits of nature during their visits under strict CDC social contact guidelines. From September through December 2020 and from January through March 2021 there were 67 and 184 visits respectively as families became more involved. The feedback from residents, families, and staff indicated that the spirits of all participants were raised by the BG visits despite the difficult challenges of social distancing and limited CLC visitations. This BG concept could serve as a model for other long-term care facilities to allow socially distant family visits to loved ones in a safe nature-based environment of care with or without a pandemic.


From Ebola, Zika, to the latest COVID-19 pandemic, outbreaks of highly infectious diseases continue to reveal severe consequences of social and health inequalities. People from low socioeconomic and educational backgrounds as well as low health literacy tend to be affected by the uncertainty, complexity, volatility, and progressiveness of public health crises and emergencies. A key lesson that governments have taken from the ongoing coronavirus pandemic is the importance of developing and disseminating highly accessible, actionable, inclusive, coherent public health advice, which represent a critical tool to help people with diverse cultural, educational backgrounds and varying abilities to effectively implement health policies at the grassroots level.  We aimed to translate the best practices of accessible, inclusive public health advice  on COVID-19 from health authorities in English-speaking multicultural countries  to adaptive tools for the evaluation of the accessibility of public health advice in other languages.  We developed an optimised Bayesian classifier to produce probabilistic prediction of the accessibility of official health advice among vulnerable people including migrants and foreigners living in China. We developed an adaptive statistical formula for the rapid evaluation of the accessibility of health advice among vulnerable people in China.  Our study provides needed research tools to fill in a persistent gap in Chinese public health research on accessible, inclusive communication of infectious diseases' prevention and management. For the probabilistic prediction, using the optimised Bayesian machine learning classifier (GNB), the largest positive likelihood ratio (LR+) 16.685  was identified when the probability threshold was set at 0.2 .  Effective communication of health risks through accessible, inclusive, actionable public advice represents a powerful tool to reduce health inequalities amidst health crises and emergencies. Our study translated the best-practice public health advice developed during the pandemic into intuitive machine learning classifiers for health authorities to develop evidence-based guidelines of accessible health advice. In addition, we developed adaptive statistical tools for frontline health professionals to assess accessibility of public health advice for people from non-English speaking backgrounds. From Ebola, Zika, to the novel coronavirus pandemic, outbreaks of highly infectious diseases continue to reveal severe consequences of social and health inequalities in both developing and developed countries , 2. VulnCurrently, there is a lack of national or international guidelines around the development of accessible and inclusive public health advice, especially for health emergencies and crises. However, the recent outbreak of coronavirus has prompted national health authorities to develop highly accessible health resources on COVID-19. Most current public-oriented health resources on infectious diseases belong to regular health resources (RHR) requiring higher levels of education, English proficiency, health knowledge, and literacy –19. TypiVulnerable people-oriented (VPO) health resources are known for their significantly improved language understandability, information relevance , social inclusiveness (applicability among diverse people), and information actionability –25. TheyIncreasing amounts of VPO health resources in English, known as easy-to-read or easy read health materials, provide valuable firsthand materials for the development of assessment instruments and techniques to support best practices in the clinic, as well as global health policy making around accessible health recommendation design and social dissemination. The development of language-adaptive evaluation instruments can facilitate evidence-based health policy making by international health authorities. For health policy makers, we developed supervised Bayesian machine learning classifiers, and for frontline health professionals we developed convenient, language-adaptable statistical analysis tools to evaluate the accessibility of public health advice on top infectious diseases, including COVID-19.It should be noted that the machine learning classifiers and statistical tools that we developed using Chinese health resources can be conveniently and reliably adapted to other languages using low-cost, relatively easy-to-obtain natural language annotation tools. In doing so, our study provides practical and useful tools for clinical and health professionals working directly with vulnerable people. The intuitive Bayesian probabilistic evaluation tool that we developed will help advance research-based global accessible health advice design and international benchmarking for the pandemic which continues to spread in many developing countries and any future public health crises that require rapid, effective, and efficient response from governments and health authorities to address the practical needs from diverse vulnerable populations and help minimise the environmental and health impacts on them.Vulnerable People-Oriented (VPO) materials (91), especially public health advice on COVID-19, were collected from websites of health authorities, including Centers for Disease Control and Prevention (CDC), Australian Ministry of Health and Public Health England. These resources were easily recognisable due to being labelled clearly as easy-to-read public health advice and instructions on COVID-19. As an international health authority, WHO provides verified professional translations of original English resources. Since our study was to develop assessment tools to evaluate accessibility of public health advice in Chinese, Chinese translations of regular WHO health advice on infectious diseases were collected. VPO resources collected from sources of CDC, the Australian Ministry of Health and Public Health, England, were translated into Chinese using forward and backward translation recommended by the WHO , and CLES = 0.966), personal pronouns , Di (tense markers) , Nd (time adverbs) , VF (action verbs as predicate objects) , and V_2 (have verbs) .High dimensional features can reduce the performance of machine learning classifiers due to the forced inclusion of irrelevant parameters in the model. To counter the issue of classifier underperformance caused by the presence of redundant features, we applied different classifier optimisation techniques to reduce the original features collected. First, we applied integral optimisation by selecting the optimised feature set from the combined MLS and POS features . This led to a combinedly optimised feature set of 6 features : average sentences per paragraph (ASPP)  between regular and vulnerable people-oriented health resources . The optimised POS feature set of 8 features : A (nonpredicate adjectives) , Cbb (correlative conjunctions) , Dfa (adverbs of degree before verbs) , Nd (time adverbs) (see above), Ng (postpositions) , Nh (pronouns) , VCL (verbs placed before locations) , and VHC (causative modifiers) . For both integral and parallel classifier optimisations, we used backforward feature elimination known as recursive feature elimination (RFE) with support vector machine as base estimator. Maximal validation accuracy/minimal classification errors were used as the feature optimisation criteria . The outputs of Bayesian machine learning classifiers are in the form of a probability of belonging to the regular public health advice training data. In our study, for the best-performing classifier (model 8: refined MLS and POS separately optimised: 2 features: ALFCW and Nh), average mean output (probability) was 0.9557  for regular public health resources and 0.022  for vulnerable people-oriented public health advice. The differences among public health advice on infectious diseases (translated to Chinese) in terms of public accessibility  were statistically significant   is another measurement of diagnostic utility. A LR + larger than 10 indicates a very large effect on posttest probability of disease or in the case of our study lack of accessibility of public health advice among some of our most vulnerable communities and people, who need accessible, actionable public health advice most. In our study, using the best-performing Bayesian classifier, the highest LR+ 16.685  was reached when setting the threshold of probability at 0.2 . This represents the safest (highest sensitivity) and the most cost-effective (lowest budget investment in expert hire) model of machine learning-assisted predictive design of accessible public health advice and information for vulnerable people and populations. We hope that this promising result based on machine learning development using low-cost, relatively easy-to-obtain natural language tools would provide more support for evidence-based, user-oriented policy making around inclusive, accessible public health advice design and communication under both regular and emergency circumstances.ALFCW (average logarithmic frequency of content words) and Nh (number of pronouns). The fitted model with the regression coefficients was shown as follows.Another major strength of our study was that we translated the best practices of accessible health advice on infectious diseases developed by English health authorities during the pandemic into adaptive analytical instruments  that can be used for the retrospective assessment of existing health advice in other languages. This was achieved by translating the English materials that we collected to the Chinese language using the forward and backward translation method recommended by WHO and comprehensively annotated the translations using Chinese natural language processing tools to allow automatic feature engineering and machine learning classifier development. The following is the binary regression formula:LR to the region of :We then used the Sigmoid Function to scale the scoreThe following formula shows Chinese health advice accessibility assessment tool (CHAAAT):We examined the performance of the CHAAAT formula on the remaining 30% test data which contained 34 highly accessible COVID-19 prevention resources translated from 3 national health authorities in the USA, Australia, and UK and 54 regular health resources on infectious diseases developed by the WHO for the public. Average mean output (transformed score using the Sigmoid Function) was 5.8958  for highly accessible, vulnerable people-oriented public health advice and resources and 88.363  for regular WHO public health resources with limited accessibility among vulnerable people with low education, limited health literacy, and limited Chinese proficiency such as foreigner migrants or people with cognitive impairments.p < 0.001, Hedges' gs = 7.248, 95% CI: 6.094, 8.401, and CLES = 1. These effect sizes were comparable to those  of probabilistic outputs of the best-performing GNB classifier using the same feature pair: AFLCW and Nh. Differences between the two sets of test data measured by CHAAAT formula were statistically very significant: Around 4% regular (requiring higher literacy and Chinese proficiency) resources were misclassified as highly accessible information and advice for vulnerable communities and people living in Chinese speaking regions. Since the 4% errors can still result in a costly overestimate of the accessibility or usability of public health advice among vulnerable populations who require highly accessible  public health information and advice, like with machine learning classifiers, we could adjust the thresholds of the CHAAAT formula to obtain the desired sensitivity and specificity pair according to the practical needs in the clinic. The design and assessment of population-oriented public health advice are high-stakes activities which require highly precise, reliable research tools to support informed, evidence-based public health policy planning and delivery. Our study showed that valuable experiences gained in the design of accessible public advice as triggered by the coronavirus pandemic can be translated to useful, much-needed research instruments and tools to support the design of public health advice for any future health events or crises. Furthermore, we developed assessment tools adaptable to other languages to facilitate international benchmarking and support global public health policy planning around accessible health risk communication and public engagement. The limitation of our study is that we used Chinese as an illustrating example which is a distinct language from English. However, the underlying techniques and methods that we discussed and demonstrated can be conveniently modified for other languages or writing systems, especially underresourced languages such as African languages and minority languages, as we developed high performing Bayesian machine learning classifiers based on small datasets. For illiterate populations, our methods need further adaptation for the assessment of oral public advice and information.


This presentation will feature innovative retention approaches that contributed to sustaining connections to older Black participants in the long-standing Healthier Black Elders Center (HBEC). The HBEC aims to address and reduce health disparities through research and education. In 2020, this outreach has included a telephone outreach program and a weekly social group, “The Party Line,” to promote connections and collect data on mental health, coping mechanisms and newly acquired skills, as well as health care access including access to masks, testing and tele-health. The presentation will also describe tailored approaches to initiating a Community Advisory Board and programming in Flint, MI and creative efforts to retain participants in Detroit, MI, thus ensuring the relationships between researchers and older community members are sustained despite program modifications.