Using Virtual Learning to Build Pediatric Palliative Care Capacity in South Asia: Experiences of Implementing a Teleteaching and Mentorship Program (Project ECHO)

Using Project ECHO to deliver a tele-mentoring and teaching program on palliative care in South Asia: Interpretive description of participants' experiences with a community of practice for learning

OBJECTIVES

To explore the learning experiences of participants (learners and teachers), in a yearlong tele-teaching and mentoring program on pediatric palliative care, which was conducted using the Project ECHO (Extension for Community Healthcare Outcomes) model and consisted of 27 teaching and clinical case discussion sessions for palliative medicine residents in India and Bangladesh. The goal of the study is to explore how participation and learning is motivated and sustained for both residents and teachers, including the motivators and challenges to participation and learning in a novel online format.

METHODS

Qualitative interviews with ECHO participants, including learners and teachers were conducted. Interviews were recorded and transcribed. Thematic analysis of interview data was conducted within an interpretive description approach.

RESULTS

Eleven physicians (6 residents, 5 teachers) participated in interviews. Key elements of the ECHO program which participants identified as supporting learning and participation include small group discussions, a flipped classroom, and asynchronous interactions through social media. Individual learner characteristics including effective self-reflection and personal circumstances impact learning. Providing opportunities for a diverse group of learners and teachers, to interact in communities of practice (COP) enhances learning. Three major themes and 6 subthemes describing learning processes were identified. Themes included (1) ECHO program structure, (2) learner characteristics, and (3) COP. Subthemes included flipped classroom, breakout rooms, learning resources, personal circumstances, self-awareness of learning needs, and community interactions.

SIGNIFICANCE OF RESULTS

Project ECHO suggests a novel model to train health providers, which is effective in low- and middle-income countries. Online learning programs can lead to learning through community of practice when learners and teachers are able to interact and engage in peer support and reflective practice. Educators should consider incorporating small group discussions, a flipped classroom design, and opportunities for asynchronous interactions to enhance learning for participants in online learning programs.

Online palliative care education and mentorship in Nepal: Project ECHO - a novel approach to improving knowledge and self-efficacy among interprofessional health-care providers

BACKGROUND

Palliative care access in Nepal is severely limited, with few health-care providers having training and skills to pain management and other key aspects of palliative care. Online education suggests an innovation to increase access to training and mentoring, which addresses common learning barriers in low- and middle-income countries. Project ECHO (Extensions for Community Health Care Outcomes) is a model of online education which supports communities of practices (COPs) and mentoring through online teaching and case discussions. The use of online education and Project ECHO in Nepal has not been described or evaluated.

SETTING

An online course, consisting of 14 synchronous weekly palliative care training sessions was designed and delivered, using the Project ECHO format. Course participants included health-care professionals from a variety of disciplines and practice settings in Nepal.

OBJECTIVES

The goal of this study was to evaluate the impact of a virtual palliative care training program in Nepal on knowledge and attitudes of participants.

METHODS

Pre- and post-course surveys assessed participants' knowledge, comfort, and attitudes toward palliative care and evaluated program acceptability and barriers to learning.

RESULTS

Forty-two clinicians, including nurses (52%) and physicians (48%), participated in program surveys. Participants reported significant improvements in their knowledge and attitudes toward core palliative care domains. Most participants identified the program as a supportive COP, where they were able to share and learn from faculty and other participants.

CONCLUSION

Project ECHO is a model of online education which can successfully be implemented in Nepal, enhancing local palliative care capacity. Bringing together palliative care local and international clinical experts and teachers supports learning for participants through COP. Encouraging active participation from participants and ensuring that teaching addresses availability and practicality of treatments in the local health-care context addresses key barriers of online education.

SIGNIFICANCE OF RESULTS

This study describes a model of structured virtual learning program, which can be implemented in settings with limited access to palliative care to increase knowledge and attitudes toward palliative care. The program equips health-care providers to better address serious health-related suffering, improving the quality of life for patients and their caregivers. The program demonstrates a model of training which can be replicated to support health-care providers in rural and remote settings.

Increasing pediatric radiation oncology capacity in sub-saharan Africa using technology: a pilot of a pediatric radiation oncology virtual training course

BACKGROUND

The shortage of skilled healthcare professionals in pediatric oncology and the limited access to training programs remain significant challenges in Nigeria and sub-Saharan Africa. The the Pediatric Radiation Oncology (Virtual) Course, 'PedROC' project aims to contribute to improving pediatric cancer outcomes in Nigeria by increasing the capacity of radiation oncology professionals. To address the gap in access to pediatric radiation oncology professional development, the PedROC project was created, harnessing technology to improve radiation oncology training via a curriculum delivered through web-conferencing. This study aimed to evaluate the effectiveness of the PedROC pilot in enhancing the capacity, confidence, and skill of radiation oncologists in decision-making, prescribing, and treatment planning of radiotherapy for children diagnosed with cancer.

METHODS

A multidisciplinary faculty of specialists in radiation oncology, pediatric oncology, oncology nursing, radiation therapy technology, and medical physics collaborated to identify the key learning needs in pediatric radiation oncology in the country. The team collaborated to develop a comprehensive curriculum covering the most common pediatric cancers in sub-Saharan Africa for the training program. The training course was conducted over two days, delivering twenty-four half-hour sessions for a total of 12 h, from July 31 to August 01, 2021.

RESULTS

Analysis of pre and post - training surveys showed a significant increase in self-reported confidence measures across all domains among radiation oncologists. The program successfully improved participants' knowledge and confidence levels in managing common pediatric cancers using radiotherapy, particularly addressing radiotherapy-specific issues such as appropriate dose, target volume delineation, treatment planning, dose constraints, and plan evaluation.

CONCLUSION

The PedROC pilot showed the efficacy of this model in enhancing the capacity and confidence of radiation oncology professionals involved in the treatment of pediatric cancer. The findings indicate that technology holds significant potential to increase pediatric radiation oncology capacity in Africa, ensuring improved access to proper treatment and ultimately improving pediatric cancer outcomes.

Does a novel community-based outpatient palliative care intervention for Parkinson's disease and related disorders improve care? Qualitative results from patients and care partners

BACKGROUND

Palliative care has the potential to address significant unmet needs in people with Parkinson's disease and related disorders, but models that rely on in-person specialty palliative care teams have limited scalability.

AIM

To describe patient and care partner experiences with a novel, community-based palliative care intervention for Parkinson's disease.

DESIGN

Qualitative study embedded in a randomized clinical trial to document participant experiences with a novel palliative care intervention (community neurologist training and remote team-based specialist palliative care). Transcripts were coded and thematically analyzed through a combination of team-based inductive and deductive coding.

SETTING/PARTICIPANTS

Twenty-eight patients and 33 care partners purposively sampled from participants in a randomized clinical trial of a palliative care intervention for Parkinson's disease and related disorders conducted at nine sites.

RESULTS

Benefits of the intervention included management of a wider range of non-motor symptoms, facilitation of conversations about the future, greater engagement with the health care team, and increased referrals to resources. Participants identified areas of improvement, including uptake of palliative care training by community neurologists, additional prognostic counseling, and clarity and timeliness of communication with the multidisciplinary team.

CONCLUSIONS

Clinicians caring for people with Parkinson's disease and related disorders should screen for non-motor symptoms, provide regular prognostic counseling, and refer to specialty palliative care services earlier in the course of illness. Future interventions should be designed to promote uptake of palliative care training by community neurologists and further optimize referral to and coordination with in-person or remote specialty palliative teams.

An Online Pediatric Palliative Care Education and Mentoring (Project ECHO) in Nepal: A Program Implementation Case Study and Assessment of Changes in Healthcare Providers' Knowledge, Confidence, and Attitudes

OBJECTIVES

The goal of this implementation study was to describe the implementation and evaluation of the impact of an online pediatric palliative care training program in Nepal, using the Project ECHO model.

METHODS

The study used mixed methods, including a program case study describing the online learning program and before-and-after surveys of program participants, assessing learning through changes in knowledge, comfort, and attitudes. An end-of-program survey was used to evaluate participants' overall experiences with the learning program and use of the learning resources.

RESULTS

A literature review, stakeholder surveys, and expert input informed the design of the intervention. The course used the Project ECHO model of online education, with modifications based on the leadership team's previous ECHO experiences and local stakeholder input. The intervention occurred over 9 months, with 22 online teaching sessions. Each session consisted of a didactic lecture, case presentation, and interactive discussion with expert clinical teachers. Fifty-five clinicians in Nepal participated, including physicians (47%), nurses (44%), and psychotherapists (5%). Clinicians reported improvements in knowledge, skills, and attitudes after program participation. Program acceptability scores were high, with 93% of participants reporting that the course provided effective learning.

CONCLUSIONS

Project ECHO can be successfully implemented to deliver continuing professional development in Nepal. Delivering palliative care education online using the Project ECHO model, leads to improved knowledge, skills, and attitudes for clinicians. Project ECHO suggests an innovative solution which can provide training and support to clinicians in settings where educational opportunities in palliative care are limited.

Effect of Personalized Email-Based Reminders on Participants' Timeliness in an Online Education Program: Randomized Controlled Trial

BACKGROUND

Postsecondary students need to be able to handle self-regulated learning and manage schedules set by instructors. This is particularly the case with online courses, as they often come with a limited number of social reminders and less information directly from the teacher compared to courses with physical presence. This may increase procrastination and reduce timeliness of the students. Reminders may be a tool to improve the timeliness of students' study behavior, but previous research shows that the effect of reminders differs between types of reminders, whether the reminder is personalized or general, and depending on the background of the students. In the worst cases, reminders can even increase procrastination.

OBJECTIVE

The aim of this study was to test if personalized email reminders, as compared to general email reminders, affect the time to completion of scheduled online coursework. The personalized reminders included information on which page in the online material the participants ought to be on at the present point in time and the last page they were on during their last session. The general reminders only contained the first part of this information: where they ought to be at the present point in time.

METHODS

Weekly email reminders were sent to all participants enrolled in an online program, which included 39 professional learners from three East African countries. All participants in the Online Education for Leaders in Nutrition and Sustainability program, which uses a question-based learning methodology, were randomly assigned to either personalized or general reminders. The structure of the study was AB-BA, so that group A received personalized reminders for the first unit, then general reminders for the rest of the course, while group B started with general reminders and received personalized reminders only in the third (and last) unit in the course.

RESULTS

In total, 585 email reminders were distributed, of which 390 were general reminders and 195 were personalized. A Bayesian mixed-effects logistic regression was used to estimate the difference in the probability of being on time with one's studies. The probability of being on time was 14 percentage points (95% credible interval 3%-25%) higher following personalized reminders compared to that following general reminders. For a course with 100 participants, this means 14 more students would be on time.

CONCLUSIONS

Personalized reminders had a greater positive effect than general reminders for a group of adults working full-time while enrolled in our online educational program. Considering how small the intervention was-adding a few words with the page number the student ought to be on to a reminder-we consider this effect fairly substantial. This intervention could be repeated manually by anyone and in large courses with some basic programming.

Project ECHO for Cancer Care: a Scoping Review of Provider Outcome Evaluations

The Project ECHO model of telementoring has been used for the past 10 years to expand access to specialized cancer care. This scoping review identifies evidence for the model's ability to improve provider outcomes, synthesizing findings from existing studies within Moore et al.'s (2009) framework for continuing medical education outcomes. We search two large research databases and a collection maintained by Project ECHO staff for articles that focus on cancer ECHO programs, involve primary data collection, and were published between December 1, 2016, and November 30, 2021. We identified 25 articles for inclusion in our scoping review. Most articles reported results for outcomes related to program participation: attendance, satisfaction, and learning. Yet, just under half reported changes in provider practices. Results demonstrate widespread participation and improved learning resulting from ECHO programs focused on cancer care. There is also evidence of improved practices related to HCV vaccination and palliative care. We highlight examples of best practices as well as opportunities to improve provider outcome evaluations for cancer ECHO programs.

Serious health-related suffering experienced by children with disability and their families living in Bangladesh: A scoping review

BACKGROUND

In 2020, the International Association for Hospice and Palliative Care redefined palliative care to incorporate the concept of serious health-related suffering. An estimated 21 million children globally live with conditions which would benefit from a palliative approach to relieve suffering. Bangladesh is a lower-middle income country with isolated provision of palliative care.

AIM

To synthesise existing evidence describing serious health-related suffering of children with disability and their families living in Bangladesh and the intersection between this suffering, palliative care and rehabilitation.

DESIGN

Scoping review methodology.

DATA SOURCES

A search strategy related to serious health-related suffering and childhood disability was applied to online databases and grey literature. English language studies (1990-2021) were included. Papers pertaining to serious health-related suffering of typically developing children and those over eighteen years were excluded. Data which addressed the three domains of serious health-related suffering (physical, social and emotional/spiritual) were extracted. Palliative care interventions were assessed with a pre-existing checklist.

RESULTS

Forty-six studies were included, representing ten different methodologies. Sample sizes ranged from 11 to 2582 participants, with 87% of studies including children with cerebral palsy. Serious health-related suffering was described in 100% of the studies, only 14 of the studies described specific interventions to mitigate suffering. Convergence between palliative care and rehabilitation approaches was evident.

CONCLUSION

Findings document the extensive nature and burden of serious childhood health-related suffering that may be remediated by a palliative approach. They highlight the urgent need to prioritise service development and research in this area.

Using Virtual Learning to Develop Palliative Care Skills Among Humanitarian Health Workers in the Rohingya Refugee Response in Bangladesh

BACKGROUND

Palliative care is an essential component of health responses in humanitarian settings, yet it remains largely unavailable in these settings, due to limited availability of palliative care training for healthcare professionals. Online training programs which connect experts to clinicians in the field have been proposed as an innovative strategy to build palliative care capacity humanitarian settings.

OBJECTIVE

To describe the implementation and evaluate the impact of delivering palliative care education using an established virtual learning model (Project ECHO) for healthcare clinicians working in the Rohingya refugee response in Bangladesh. Program acceptability and the impacts on learners' self-reported knowledge, comfort, and practice changes were evaluated.

METHODS

Using the Project ECHO model, an education program consisting of 7 core sessions and monthly mentoring sessions was developed. Each session included a didactic lecture, case presentation and interactive discussion. Surveys of participants were conducted before and after the program to assess knowledge, confidence, and attitudes about palliative care as well as learning experiences from the program.

RESULTS

This virtual palliative care training program engaged 250 clinicians, including nurses (35%), medical assistants (28%) and physicians (20%). Most participants rated the program as a valuable learning experience (96%) that they would recommend to their colleagues (98%). Participants reported improvements in their knowledge and comfort related to palliative care after participation in the program, and had improved attitudes towards palliative care with demonstrated statistical significance (p < 0.05).

CONCLUSIONS

Virtual training is a feasible model to support healthcare providers in a humanitarian health response. Project ECHO can help to address the urgent need for palliative care in humanitarian responses by supporting healthcare workers to provide essential palliative care to the growing number of individuals with serious health-related suffering in humanitarian settings.

Barriers and Facilitators to Implementing Project ECHO in Malaysia During the COVID-19 Pandemic

Objective: In Malaysia, HIV is concentrated among key populations who experience barriers to care due to stigma and healthcare discrimination. The COVID-19 pandemic has increased barriers to healthcare. Project ECHO (Extension for Community Healthcare Outcomes) is a transformative tele-education strategy that could improve HIV prevention and treatment. Methods: Practicing physicians who were aged 18 years or older and had internet access participated in asynchronous online focus groups. Results: Barriers to Project ECHO were conflicting priorities, time constraints, and technology. Facilitators included content and format, dedicated time, asynchronized flexible programming, incentives, and ensuring technology was available. Conclusion: Project ECHO is a promising intervention that can increase physicians' knowledge and skill set in specialty medicine during the COVID-19 pandemic. Interventionists in Malaysia in particular, but also in general, should consider these barriers and facilitators when developing Project ECHO as they may aid in developing a more robust program and increase participation.

Reflections on project ECHO: qualitative findings from five different ECHO programs

Project ECHO (Extension for Community Healthcare Outcomes) was developed in 2003 as an innovative model to facilitate continuing education and professional development. ECHO emphasizes 'moving knowledge, not people.' To accomplish this, ECHO programs use virtual collaboration and case-based learning to allow practitioners, including those in rural and underserved areas, to receive specialist training. The ECHO model has expanded rapidly and is now used in 44 countries. Preliminary research on ECHO's efficacy and effectiveness has shown promising results, but evidence remains limited and appropriate research outcomes have not been clearly defined. To improve the evidence basis for ECHO, this study of 5 ECHO programs (cancer prevention/survivorship, integrated pain management, hepatitis C, HIV, and LGBTQ+ health care elucidated actionable insights about the ECHO programs and directions in which future evaluations and research might progress. This was a qualitative study following COREQ standards. A trained interviewer conducted 10 interviews and 5 focus groups with 25 unique, purposively sampled ECHO attendees (2 interviews and 1 focus group for each of the 5 programs). Data were transcribed verbatim and analyzed using the general inductive approach, then reviewed for reliability. We identified four major categories (reasons to join ECHO, value of participating in ECHO, ways to improve ECHO, and barriers to participation) composed of 23 primary codes. We suggest that thematic saturation was achieved, and a coherent narrative about ECHO emerged for discussion. Participants frequently indicated they received valuable learning experiences and thereby changed their practice; rigorous trials of learning and patient-level outcomes are warranted. This study also found support for the idea that the ECHO model should be studied for its role in convening communities of practice and reducing provider isolation as an outcome in itself. Additional implications, including for interprofessional education and model evolution, were also identified and discussed.

Community Hospice Nurses' Perspectives on Needs, Preferences, and Challenges Related to Caring for Children With Serious Illness

IMPORTANCE

Many of the 50 000 children who die annually are eligible for provision of community-based hospice care, yet few hospice organizations offer formal pediatric services. Population-level data demonstrate that hospice nurses lack training, experience, and comfort in caring for children, but their specific educational needs and preferences are poorly understood.

OBJECTIVE

To assess the pediatric-specific training and support needs of hospice nurses caring for children in the community.

DESIGN, SETTING, AND PARTICIPANTS

For this qualitative study, 41 nurses were purposively seletected from a population-level cohort of 551 hospice nurses who completed a previous mixed-methods survey; these 41 nurses participated in semistructured interviews between February and April 2019. Hospice nurses were recruited from all accredited hospice organizations in Tennessee, Mississippi, and Arkansas that offer care to pediatric patients. Content analysis of interview transcripts was conducted.

MAIN OUTCOMES AND MEASURES

The interview guide probed for topics related to prior pediatric hospice training experiences, desires and preferences for training, and perceived barriers to training.

RESULTS

Interviews were conducted with 41 nurses representing different geographic regions and levels of comfort with pediatric hospice provision (as self-reported in the prior survey). Thirty-eight of the nurses were women (92.7%), with a median age of 40-49 years (range, 20-29 to ≥60 years) and median tenure of 5-9 years (range, <1 to ≥20 years) as a hospice nurse. Respondents included 1 American Indian or Alaska Native nurse (2.4%), 1 Black nurse (2.4%), and 39 White nurses (95.1%). Across interviews, most hospice nurses reported feeling uncomfortable caring for children with serious illness, and all nurses used language to express the immediacy behind the need for pediatric-specific training and support. Nurses explained why further training and support are needed and clear preferences for who should provide the education, educational modalities, and specific training topics. Nurses also articulated barriers to training and support opportunities and proposed innovative suggestions for overcoming these challenges. Notably, nurses emphasized the need for connection with experts, a sense of community, and solidarity to support frontline clinicians providing end-of-life care to children in the community.

CONCLUSIONS AND RELEVANCE

In this qualitative study, community hospice nurses expressed an urgent need for improvements in pediatric-specific training opportunities and support, clear preferences for how education should be provided, and recommendations for circumventing barriers to training. These findings are a call to action for the palliative care community to collaborate in rapid implementation of educational programs and networks to systematically support hospice nurses caring for children in the community.

Exploring Health Professionals' Experiences With a Virtual Learning and Mentoring Program (Project ECHO) on Pediatric Palliative Care in South Asia

Project ECHO (Extension of Community Healthcare Outcomes) is an innovative model of online education which has been proposed to enhance access to palliative care in resource-limited settings. There is limited literature describing how health care providers in low-and middle-income countries benefit from and learn from this type of training. This qualitative description study explores the learning experiences of participants in a Project ECHO program on pediatric palliative care in South Asia through focus group discussions. Discussions were transcribed, coded, independently verified, and arranged into overarching themes. We identified learning themes including the importance of creating a supportive learning community; the opportunity to share ideas and experiences; gaining knowledge and skills, and access to additional learning materials. Designing future programs to ensure a supportive and interactive learning community with attention cultural challenges may enhance learning from future Project ECHO programs.

The Looming Threat: Cancer in Sub-Saharan Africa

Recent trends in cancer epidemiology in low‐ and middle‐income countries show the need for urgent action. This article focuses on sub‐Saharan Africa, where populations are showing an increased risk for diseases associated with the Western lifestyle, including cancer.