A model for global health education through the Ethiopian newborn quality improvement ECHO initiative

Abstract

Objective

The Ethiopian Newborn Quality Improvement (EN-QI) Extension for Community Healthcare Outcomes (ECHO) promoted the implementation of Helping Babies Survive training in eight Ethiopian health facilities. The initiative incorporated U.S based Neonatal-Perinatal Medicine (NPM) fellows into the ECHO Expert Hub. This study evaluates the experiences of the NPM fellows.

Study design

This mixed-methods study incorporated objective data, survey responses, and qualitative focus group analysis from the eight participating fellows.

Results

Fellows described benefits including mentoring, networking, career development, and quality improvement experience. Their experience would have been improved with more thorough onboarding and clarification of the fellow role at the start of the project.

Conclusion

This study demonstrates a model for inclusion of fellows in a virtual partnership as a low-cost and high value approach to global health work. This project was well-received and highly valued by fellows as a meaningful training opportunity.

Introduction

Increased awareness of discrepancies in health outcomes between high-income countries (HICs) and low- and middle-income countries (LMICs) has fueled involvement in global health initiatives across medical specialties [1–3], including neonatal-perinatal medicine (NPM) [4, 5]. This interest has been matched by a growing recognition of the need for equity in global health partnerships [6]. Current global health practice recommendations include recognition of persistent power imbalances between partner countries [7], focus on intervention sustainability [8], and enacting study priorities identified by LMICs [9–11]. Concurrently, medical trainees in both HICs and LMICs engaging in global health partnerships are at a formative period in their professional development, which affords a unique opportunity to instill the importance of equity in research and quality improvement (QI) initiatives in LMICs [6, 12].

As a result of increasing interest in global health, many US training programs offer the opportunity for residents and fellows to be involved in international activities. As of 2016, 73% of pediatric residents reported that global health opportunities were available at their institution, with 13.5% of residents spending time abroad during their residency training [13]. Within NPM, approximately half of all training programs report opportunities for their fellows to participate in global health initiatives [4]. Despite this, engagement in global health at the NPM fellow level is around 21%; this is well below participation rates in residency training and less than half as common as global health experiences in medical school [4]. With 47% of all under-five mortality occurring in the neonatal period and 98% of neonatal deaths occurring in LMICs [14], it has never been more critical to prioritize neonatal global health [12]. A key avenue for increasing global neonatal efforts is for NPM fellows to engage globally. Currently, where they do exist, global experiences at the NPM fellow level remain primarily clinical with limited exposure to QI or research partnerships, or health systems strengthening [4]. With research and QI being central elements to subspecialty training, there is a clear need to provide these types of opportunities to NPM fellows interested in global health careers [12]. Gaps in quality of care during and immediately following delivery contribute to adverse birth outcomes [15], and QI science has been shown to improve facility-specific adherence to international standards of essential newborn care (ENC). The capacity to engage virtually in global health initiatives is increasing [16] and may be a promising avenue for NPM fellows.

Project ECHO (Extension for Community Healthcare Outcomes) is a telementoring educational model that connects community healthcare providers with specialists [17]. By connecting providers in remote or underserved areas with topical experts, ECHO aims to build local capacity through acquisition of knowledge and relevant skills. ECHO uses an “all teach, all learn” design to foster this relationship, with specialists (in the ECHO model, termed “the hub”) providing teaching and mentorship to several community sites (the participants), who also learn from one another [18]. The hub and participants connect virtually via structured meetings that incorporate didactic teaching, case presentations by participants, and group discussions. Project ECHO has been identified as a promising strategy to address health education and collaboration in remote or resource-limited settings [18, 19]; however, few studies have been conducted in LMICs [20]. Furthermore, the potential for ECHO to serve as a vehicle for specialty mentorship for medical trainees has not yet been explored.

The Ethiopian Newborn Quality Improvement (EN-QI) ECHO Initiative aimed to promote the translation of Helping Babies Survive (HBS) training in Ethiopian hospitals into sustainable practice change by targeting quality gaps through a mentorship model using the ECHO model [21]. The initial focus of the EN-QI ECHO was delivering a curriculum of QI methodology utilizing the example of delayed cord clamping (DCC). The initiative intentionally incorporated trainees in US-based NPM fellowships as learner partners in the ECHO Expert Hub. This approach was intended to allow experienced global health neonatologists to model an equity-focused, partnership-based implementation program. Notably, there are only two NPM fellowship programs in Ethiopia, which do not encompass the study sites in EN-QI ECHO; due to the need for constant presence at the study sites, no Ethiopian NPM fellows were involved in this initiative. The EN-QI ECHO Initiative’s clinical and QI outcomes are presented elsewhere [21]. The objectives of this study were to evaluate the experiences of the NPM fellows who participated in the EN-QI ECHO Initiative, and to assess functionality and effectiveness of the paired mentor-mentee model in the Expert Hub.

Materials and methods

Program structure

The EN-QI ECHO Initiative represents a year-long program developed by the Ethiopian Pediatrics Society (EPS) and the American Academy of Pediatrics (AAP). The AAP serves as an ECHO Superhub, and a pediatric training arm of the ECHO Institute. Through this role, the AAP supports partner organizations, such as the EPS, to serve as hubs. The overarching goal of the EN-QI ECHO initiative was to improve the quality of newborn care utilizing HBS training at participating hospitals through a focused QI project selected by each site. A secondary goal was to model equitable and sustainable global health practices to NPM fellows by integrating them into the US team and allowing them to observe, and contribute to, bilateral exchange of knowledge between the US and Ethiopian ECHO participants.

In 2020, the EN-QI Partnership launched in select birthing hospitals in Addis Ababa, Ethiopia. Eight hospitals were selected by the EPS to participate in this QI initiative. A midwife was identified at each site to serve as the site leader and QI coach. Site leaders were paired with a US team, consisting of a SoNPM neonatologist and an NPM fellow. The neonatologist and the NPM fellow were identified after a call for applications led by the AAP Section on Neonatal-Perinatal Medicine (SoNPM) Subcommittee on Global Health. The EN-QI ECHO therefore employed a modified hub-and-participant model. The EPS served as the hub, with the eight US neonatologist-fellow pairs comprising an advisory council linked to the hub; the eight Ethiopian midwives and their delivery centers represented the participants. The Ethiopian QI coach served as the team lead at their center and was responsible to spreading QI practices within their delivery room and coordinating new study processes, data collection, and data reporting. The Ethiopian sites were selected by EPS leadership and included eight delivery centers throughout Addis Ababa. The structure of the EN-QI ECHO project can be seen in Fig. 1.

Fig. 1. Structure of EN-QI ECHO project.

NPM fellows were paired with a US NPM faculty member and an Ethiopian EN-QI coach. Fellow-specific elements of the project focused on career development within global health. EN-QI ECHO Ethiopian Newborn Quality Improvement Extension for Community Healthcare Outcomes, NPM Neonatal-Perinatal Medicine.

The EN-QI ECHO sessions were held monthly from February 2021 through January 2022. Each session consisted of didactic lectures, taught in Amharic (the primary language of Ethiopia) and led by the EPS Executive Director. Post-session discussions occurred via a combination of Amharic and English; all Ethiopian participants were conversational in English and used this language when discussing educational content with US team members. Session topics followed the content layout of the HBS QI Guide [22], which was translated into Amharic and provided to all participants. Session 1 focused on an overview of HBS principles and the topics that could fall under the broad goal of improving delivery room outcomes. Centers then identified gaps that could be addressed within their own centers and collectively decided to focus on DCC for this year-long initiative. Each site set an aim that was Specific, Measurable, Achievable, Realistic, and Timebound (SMART) for local improvement in DCC. Monthly virtual ECHO sessions were held to focus on QI training, peer learning, and site-specific progress and challenges. All sessions used the multi-point video-conferencing software Zoom. All US team members and Ethiopian Coaches were members of a WhatsApp® [23] group chat that allowed additional discussion of key learning points between the monthly sessions.

Mentorship structure for NPM fellows

Eight NPM fellows partnered with eight AAP SoNPM neonatology project mentors. These mentor-mentee pairs functioned as advisor teams and were paired with a QI coach at one of the eight Ethiopian centers. Fellows were intentionally matched with a neonatologist at a different institution to foster cross-institution networking. Fellows received a tailored orientation session that included information on historic inequities in global health, collaborative research, how to avoid exploitative practices when engaging in global health throughout their careers, and focus on localization. Global health career development guidance continued throughout the year-long EN-QI ECHO project. The AAP leaders and neonatologists held four virtual “coffee and career” sessions where fellows could learn about the career paths of the faculty, ask questions about careers in global health, and discuss their goals with both mentors and peers. Fellows also had access to fellows-only WhatsApp chat, allowing them to discuss their experiences in this EN-QI ECHO Initiative, and build a community of global-health focused NPM fellows. Lastly, the fellows were encouraged to ask questions and learn from their Ethiopian partners in order to get the lived perspective of people proving delivery room care in Ethiopia.

Data collection and analysis

To assess the impact of the EN-QI ECHO on the NPM fellows, our team used a mixed-methods approach. This approach combined objective attendance data, pre- and post-program surveys, and post-program focus group interviews.

Attendance data were collected in real-time during monthly Zoom meetings and recorded in a logbook.

Surveys were sent out to the US fellows before the launch of the program and following the end of the program. Surveys were collected in paper / PDF format and transcribed into Microsoft Excel [24] before analysis. Two focus groups were held in September 2022 to explore fellows’ experience of the EN-QI ECHO program. Focus groups were led by an AAP ECHO evaluation manager. A semi-structured discussion guide was used to focus the discussion. The stated purpose of the focus groups was to better understand fellows’ hopes and expectations for the project, reasons for participating, perceptions of their experiences, satisfaction with the project, assessment of the training experience, and lessons learned. Focus group discussions were hosted on Zoom and recorded with consent from participants for data analysis purposes.

Audio from each focus group was transcribed verbatim by the facilitator. Transcripts were de-identified and entered into nVIVO 12.0 [25] for analysis. Any identifying information was removed prior to thematic coding. A conventional content analysis approach was used, wherein codes were derived directly from the transcribed text [26]. Codes were developed for major themes that emerged and were synthesized and organized according to the main areas of focus in the facilitated discussion guide. Categories were identified and combined into broader themes. Prior to formal analysis, the study team met to review the codebook, discuss examples that could be associated with each code, and reach consensus about the meaning of each code. Preliminary coding was performed by authors SR, CC, and JJ. None of the coders were fellow participants. The three coders all coded both focus group transcripts. Intercoder discrepancy was discussed and resolved by consensus. Analysis was iterative, with transcripts being reviewed multiple times to ensure that the analysis reflected the inclusion of emergent and developing themes.

Results

Demographics and background of NPM fellow participants

Eight NPM fellows participated in the EN-QI ECHO. Seven were identified as female, and one as male. They represented second- and third-year fellows from eight distinct US-based institutions.

All eight NPM fellows completed the pre- and post-program surveys. Six (75.0%) had prior global health training. This consisted of certificate programs (n = 3, 37.5%), formal or informal “global health tracks” in residency (n = 2, 25.0%), and master’s level training in global public health (n = 1, 12.5%). Two fellows (25.0%) felt that they had strong global health mentorship within their current NPM fellowship program, and five (62.5%) felt that they had such mentorship outside of their fellowship program. All five of these fellows commented that their global health mentors were from residency training.

Fellows were also asked to reflect on the time they had spent engaging in global health prior to the EN-QI ECHO and their associated depth of involvement in global health activities. Half of the fellows classified themselves as “advanced beginners” both for time and depth of past engagement. Only two (25.0%) fellows noted that they were “proficient” in regard to time spent in global health, and no fellows felt that they were “proficient” or “expert” in relation to global health involvement prior to the EN-QI ECHO. Definitions were created by faculty engaged in the EN-QI ECHO (Table 1).

Table 1.

Fellow global health experience prior to EN-QI ECHO participation.

Time spent in global health prior to EN-QI ECHO
Self-assessed level	N	Definition
Novice	0	I have been on 1–2 short trips, such as less than 10 days. Trips were short team-based mission trips or associated with university or charities, with volunteer, clinical work or shadowing
Advanced beginner	4	I have been on 1–3 trips, either short (<10 days) or medium (10-30 days) length, associated with a global health partnership or rotation in residency or medical school.
Competent	2	I have been engaged in global health through 3 or more trips, some of which have been multi-week trips, or I have participated in repeated trips to global health partner sites.
Proficient	2	I have engaged in global health for 5 or more global health trips, been engaged continually for more than 2 years in global health or have participated in repeated trips to locations for longitudinal work, experiences >1 month in duration.
Expert	0	I have engaged in global health routinely for more than 5 years, 8 or more trips, and engaged in a sustained, longitudinal partnership over 6 months.
Experience and involvement in global health prior to EN-QI ECHO
Self-assessed level	N	Definition
Novice	1	I have been involved in short volunteer-based trips, through a faith-based organization, school, or other programs. On trips, I have been a clinical volunteer, shadowing and seeing patients in an inpatient or outpatient setting.
Advanced beginner	4	I have participated in a structured global health partnership visit, through an academic institution or other formal partnership, involving single-visit engagement between local health providers and visiting US providers. I may have provided direct patient care.
Competent	3	I have been engaged in an intervention, quality improvement, or implementation science-based global health partnership, with an active role in this implementation. My engagement was part of a set partnership, with repeated visits, and outlined goals.
Proficient	0	I have been engaged in multiple global health experiences with increasing rigor, which have included aspects of capacity building or quality improvement. I have had an active role in a global health research, QI, or intervention team. Such experiences may have involved governmental, NGO, or large academic partnerships.
Expert	0	I have had direct or advanced involvement or leadership of a capacity building, large intervention, research, or quality improvement global health project. Such experiences may have involved large-scale academic partnerships or coordination with governmental leadership such as a Ministry of Health.

EN-QI ECHO Ethiopian Newborn Quality Improvement Extension for Community Healthcare Outcomes.

Attendance at monthly virtual sessions

There were 12 monthly EN-QI ECHO sessions from February 2021 to January 2022. Attendance data were available from nine (75.0%) of these sessions. The average attendance rate amongst the NPM fellows was 40.3%, with a maximal attendance rate of 66.7%. Attendance at inpatient rounds at their home institution was the most common reason reported for lack of attendance at any given session.

Comfort with global health

Two questions appeared both on the pre- and post-program surveys. These questions assessed comfort working in a different cultural context and comfort working with research partners based in another country. Over the course of the EN-QI ECHO program, there was an increase from three (37.5%) to six (75.0%) fellows stating that they were very comfortable working in a cultural context other than their own. When asked about their comfort working with research partners in another country, one participant (12.5%) felt somewhat uncomfortable prior to the study; no participants felt very uncomfortable. Post-study, no participants felt uncomfortable. However, there was a slight shift towards being neutral (Pre: 0.0%, Post: 25.0%) rather than very or somewhat comfortable (Pre: 87.5%, Post: 75.0%). For all observations p > 0.05 and were not considered statistically significant.

Mentorship and program experience

In the post-program assessment, all respondents agreed or strongly agreed that they were able to form a meaningful connection with their US faculty mentor. The majority were either neutral or disagreed when asked if they were able to form a meaningful connection with their Ethiopian partner coach. Despite this, all participants agreed or strongly agreed that participation in this project was helpful to their career development and that the informal mentoring sessions with the US faculty were helpful (Table 2).

Table 2.

Mentoring and career development experiences among Neonatal-Perinatal Medicine fellows participating in the EN-QI ECHO project, Post-Program Assessment.

Question	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Strongly Agree or Agree (%)
I was able to form a meaningful connection with my US faculty mentor	0	0	0	5	3	100
I was able to form a meaningful connection with my Ethiopian partner coach	1	2	3	1	1	25
I felt that I was “part of the team” and contributing to the overall goals of the project	0	0	4	2	2	50
I found the informal group mentoring sessions with the US faculty helpful	0	0	0	3	5	100
I found participating in the AAP-EPS project helpful for my career development	0	0	0	4	4	100

AAP American Academy of Pediatrics, EN-QI ECHO Ethiopian Newborn Quality Improvement Extension for Community Healthcare Outcomes, EPS Ethiopian Pediatrics Society.

When asked to select from a predefined list and indicate what they gained by participating in the EN-QI ECHO project, “networking with other trainees and faculty in global health,” “exposure to the QI process,” and “experience working with international partners” were the most frequently selected. Networking was selected as the most important component by 50.0% of NPM fellow participants. Fellows also provided open-ended responses explaining why their selected choice was the most important (Table 3).

Table 3.

Skills or experiences gained from the EN-QI ECHO by participating fellows (n = 8).

Option	Yes responses	Most important	Participant quote
Networking with other trainees and faculty in global health	8	4	Prior to this project, I sometimes felt like an anomaly in my interests in neonatology and global health, so finding a group of people who were actively thinking about these topics and had made this their career was extremely helpful to me.
Exposure to the QI process	8
Experience working with international partners	7	1	I have been on multiple international trips where I worked in hospitals, but I have not collaborated in a group project in this way.
Experience working with the AAP / SoNPM	6
Better understanding of the process of conducting projects across multiple centers	6
Experience with remote collaboration	6	2	During COVID, my global health plans for fellowship were interrupted. However, this project gave me the opportunity to still be involved in global health collaboration and research as a trainee.
Global health mentorship	6	1	Having consistent contact with so many leaders in local, national, and international neonatal health was the most impactful part of the project.
Contribution to a scholarly work product, such as a publication, in global health	4

AAP American Academy of Pediatrics, EN-QI ECHO Ethiopian Newborn Quality Improvement Extension for Community Healthcare Outcomes, SoNPM Section on Neonatal-Perinatal Medicine.

Focus group discussions on program experience

All fellows were invited to provide feedback on the program via post-program focus groups. Four fellows participated. Those who did not participate all cited an inability to make the scheduled focus group meeting time. Inductive codes were applied describing mentorship experience, networking, experience with the virtual ECHO platform, cross-country communication, project onboarding, and implementation. Following coding, three overarching or organizing themes emerged related to (1) career development, (2) cross-cultural partnership, and (3) areas for project improvement. Together, these organizing themes support a singular global theme: The EN-QI ECHO Program served as a successful model for fellow engagement in global health and can be further improved by enhanced focus on fellow onboarding and targeted mentorship throughout the program. Figure 2 illustrates the conceptual framework that emerged from the data.

Fig. 2. Organizing and global themes identified from focus groups of Neonatal-Perinatal Medicine fellows participating in the EN-QI ECHO project.

EN-QI ECHO Ethiopian Newborn Quality Improvement Extension for Community Healthcare Outcomes.

Career development and the EN-QI ECHO initiative

All of the NPM fellows who participated in the post-program focus groups highlighted the value of the EN-QI program in their career development. Overwhelmingly, the benefit of the experience was reflected in the pairing of NPM fellows with SoNPM neonatologists with significant global health experience. Fellows noted how, when applying to be a fellow participant in the EN-QI ECHO, they looked forward to “being involved in an organization outside of my institution” (Participant 2) and “learning from leaders in our field” (Participant 4). By pairing each NPM fellow with a neonatologist, fellows had the opportunity to learn one-on-one from their mentor and witness how more experienced global health physicians navigated virtual partnerships. This was seen as especially important in the context of the COVID-19 pandemic. One fellow highlights this in her commentary:

“My biggest hope was really just to get to learn from the faculty leads … to learn from the Ethiopian coaches and learn about how to work together collaboratively on an international platform, virtually because I think we all got hit by this - I was supposed to spend a month every year of my fellowship in [a global setting], working on my quality improvement projects, and it became impossible, because of COVID.”(Participant 4)

Fellows commented on the value of seeing their mentor work with the AAP, EPS, and local team to navigate project-specific challenges, programmatic delays, and data management questions that arose throughout the study. They also noted the importance of witnessing a good mentoring relationship that valued the role and the experience of the Ethiopian coaches.

“I think it was nice to get to watch other people navigate those challenges and glean some little pearls about how to adjust projects that I’m going to work on in the future.” (Participant 2)

“It was really helpful for me just to kind of see that model of how to be a good mentor, how to work on a project collaboratively to be able to support [the Ethiopian coaches] without being overbearing and having too much control.” (Participant 4)

Because the project fellows and neonatologists came from a wide range of US academic institutions, engaging fellows in the EN-QI ECHO also allowed for valuable networking. Some mentor-mentee dyads were able to meet in person to further strengthen their mentoring relationship. As one fellow described, “The incredible thing was during this I was able to meet up with my mentor in person at PAS [Pediatric Academic Societies] and go to one of the talks they were doing about global health.” (Participant 2) Outside of their one-on-one pairings, the fellows appreciated the opportunity to engage with all of the US-based neonatologists in a series of informal career-focused “coffee chats”. These allowed time for fellows to hear about career journeys and ask specific questions about launching a career in neonatal global health.

“They had a group of the mentors come in and kind of just chat about career, about life balance, and different directions that they could go with their projects that they were doing outside of this work. It gave access to a lot more people [faculty] in the group and the additional advice that came through that.” (Participant 3)

Another key element of their personal growth and career development was the community the fellows felt amongst their NPM fellow peers. Fellows described how valuable it was to simultaneously learn from their mentors and to meet fellows who were also learning to be global health researchers. This helped them build a community that would “go beyond this project” (Participant 1).

Cross-cultural partnership

The second organizing theme identified by our fellow focus group was how the cross-cultural partnership between the US and Ethiopia was a key strength of the study but was not without challenges. Several of the focus group participants highlighted how participating in EN-QI ECHO allowed them to engage with partners in LMICs despite not being able to travel: “I think it was a great creative way to say, ‘how can we continue with ongoing education without physically being in the country?’” (Participant 4)

Others viewed the virtual platform as a novel way to connect partners in a more individual way that has distinct value from the large group settings. As one fellow noted, “Our one-on-one sessions (WhatsApp video calls) were really helpful, because it allowed us the opportunity to meet directly, see their setting, … and really talk about ‘what are the challenges in your unit? Where are your gaps? How do we address this?’” (Participant 1). Importantly, the EN-QI Project took place during the COVID-19 pandemic. Fellows praised how a virtual global health project allowed them to continue working in the neonatal global health space, supporting partners in the group, while not being able to travel. One fellow reflected, “I [the virtual platform for EN-QI ECHO] increased my interest in the project because I think we all felt stuck, I mean, as [fellows] who are trying to do global health work and are not able to be in the places where the research is happening.” (Participant 4)

Remote partnership also had its limitations. Most notably, the fellows described feeling unaware of what was happening on the ground between meetings and thus were not sure how to assist, stating “I wasn’t always sure what they needed from me for the project between the sessions.” (Participant 2) Lastly, fellows felt that the virtual nature of the project limited engagement due to logistic and technical constraints. Fellows cited “getting everybody to get on the zoom on time, connection errors, people, and not muting themselves” (Participant 2). At the same time, witnessing how their neonatologist mentors navigated these challenges was helpful to the fellows, giving them the realization that “So this happens to all of us” (Participant 4).

Program gaps

While the fellows uniformly affirmed the strengths of the EN-QI ECHO Initiative, when reflecting on the program as an avenue for fellow global health engagement, the participating fellows identified gaps in communication and organization that limited the full potential of program participation for fellows. First, a few participants stated that the role of a fellow “wasn’t well delineated” (Participant 3). Fellows felt like they were functioning both as teachers and mentees but were not clear on how much of a leadership role to take in the program: “How do I help other people across the world, with all of these barriers, accomplish a QI project when I myself am learning?” (Participant 1)

Similarly, fellows noted that their paired mentors focused on the fellow’s career development goals rather than how the fellow should contribute to the EN-QI ECHO. One fellow stated, “I do think that the mentors tried to say, like, what are your career goals? … I think this was lovely and one of the things I wanted from this, but I don’t think that that was within the direct scope of the project in terms of being a QI project in hospital sites and Ethiopia.” (Participant 2)

Lastly, fellows expressed a desire to be more integrated into project planning discussions. For example, one fellow shared that they were not sure how delayed cord clamping was selected as the focus of EN-QI ECHO, noting that “in meeting directly with our Ethiopian coach he you know, at the beginning of the project we had actually identified a slightly different gap that we wanted to focus on” (Participant 2). Interestingly, another fellow responded with clarifying understanding, paraphrasing the alignment of QI projects between sites as “let’s get everybody on board with the same project, so that we can have a successful project … and see some change and walk everybody through the QI process, and at least you’ll learn from each other in the process.” (Participant 3)

Discussion

In this report, we focus on the impact of EN-QI ECHO on US NPM fellows. For these learners, the EN-QI ECHO program served as a novel model for fellow, and other trainee, engagement in global health and offered a unique opportunity for US fellows to be immersed in a QI project co-led by the EPS and the AAP. EN-QI ECHO allowed these fellows to experience first-hand the successes and challenges associated with virtual global health work. The NPM fellows described benefits such as mentoring, networking, career development, and QI experience. Areas for further refinement included clarification of the fellow role, more thorough onboarding for fellows at the start of the project, and engagement of Ethiopian trainees as co-learners alongside US fellows.

Global health is increasingly being recognized as an important component of medical education [1, 2, 27], including among pediatric subspecialties [28] and Neonatal-Perinatal Medicine (NPM) fellows [4]. Guidance on HIC NPM fellow training in global health highlights how such training requires strong local and institutional mentorship [12]. Unfortunately, defined mentorship is not universal in pediatric or neonatal global health experiences [4, 29]. The EN-QI ECHO Initiative used a novel cross-institution mentorship model to pair fellows with neonatologists engaged in global health. This approach was viewed very favorably by fellows, as it fostered networking with US neonatology faculty and the ability to meet NPM fellow peers interested in global health. Indeed, networking was cited as the top priority by fellows in our post-program feedback. The use of strong cross-institutional mentorship, especially for fellows aspiring for a research career, has been promoted by groups such as the Organization of Neonatal Training Program Directors [30]. A virtual cross-institutional mentorship model, such as that used in EN-QI ECHO, allows for guidance both within a mentor-mentee dyad as well as at a larger group level. The EN-QI ECHO also fostered informal mentorship through “coffee talks”, which decreased barriers to engaging with neonatal leaders in global health. Here, casual networking allowed fellows to see the range of career paths used by US-based neonatologists working in global health, which served as potential models for their own post-fellowship careers. Informal mentoring has been shown in a variety of educational settings to have positive benefits such as the ability to discuss work-life balance and career opportunities and to engage in peer-mentoring [30–32].

The EN-QI ECHO program was carried out during the COVID-19 pandemic which allowed for unique insight into virtual fellow engagement in global health using various platforms at a time when on-the-ground opportunities were not available. Globally, the forced move to virtual collaboration fueled the development of several virtual platforms for partnership and engagement [33–35]. Due to the pandemic, there was a need to reexamine how we structure partnerships in the setting of a global travel ban, which raised important issues related to disparities, inequity, and neocolonialism [34, 36]. The pre-pandemic practice of U.S. trainees traveling abroad was critiqued for often being short-term, expensive, and of unclear direct benefit to the host country [37]. Expert guidance on post-pandemic global health work suggests shifting to virtual programs allows for broader trainee involvement, the opportunity for learner-to-learner partnership, and greater project continuity [34]. The participating fellows felt that the EN-QI ECHO met these metrics and served as a strong virtual partnership. While the EN-QI ECHO program did not engage NPM fellows in Ethiopia, the direct pairing of faculty-fellow dyads in the US and midwife coaches / learners in Ethiopia, allowed participants in both countries to serve simultaneously as educators and learners. The program fostered relationships between the US fellows and Ethiopian Coaches as co-learners in QI, encouraging communication at a group and individual level. While not all fellows reported a “meaningful connection” with their Ethiopian partner coach, all felt that the small groupings were an asset to the project. This perceived lack of connection, however, raises concerns about what level of personal connection can be formed virtually, and should be expected by participants, especially in the setting of language barriers. Indeed, virtual global health work cannot fully replicate the human-to-human experience of working in another clinical and cultural setting. Future virtual partnerships can learn from our experience and incorporate more guidance on expectations for between-session communication and create project-specific avenues to foster connection between participants that consider language, time zone, or technology barriers.

The primary critique from fellows about the EN-QI ECHO program was a lack of understanding about their defined role and of the pre-implementation work that was carried out by leaders within the EPS and the AAP. The EN-QI ECHO was not designed as a fellow-focused program, but rather as a QI implementation project run by the EPS with AAP support. The incorporation of US fellows into the EN-QI ECHO was done so that fellows could observe a virtual global health project between partner pediatric societies and, hopefully, have modeled for them how to equitably engage in such projects. Experts in decolonizing global health highlight the criticality of shifting the balance of decision-making power, from project design to implementation, to the setting in which the research will take place [38]. In the EN-QI ECHO, the EPS had primary ownership of the project. As such, the US team was less central and served in an advisory and mentorship role. Based on fellow feedback, NPM fellows may desire a more complete understanding of project conception and organization to comfortably participate. Furthermore, to ensure equitable access for NPM fellows, in future projects both HIC and LMIC leaders should think proactively about how to incorporate LMIC fellows, and other trainees, as co-learners in a role similar to the US NPM fellows in EN-QI ECHO.

For in-country global health experiences, most trainees, including fellows, go through structured pre-departure preparation that focuses on cultural competencies, ethics, partnership, and communication [39–41]. While an hour-long pre-program orientation was held for the EN-QI ECHO fellows, results from our focus groups, demonstrate a need for enhanced pre-participation training. In our study, we saw an increase in post-program fellow comfort working in a different cultural setting, but minimal change in comfort working with a research partner in another country. Several fellows associated this discomfort with being unsure of their impact within the project. Recommendations on NPM fellows involvement in global health elevate the concept of learning to “lean out”, removing oneself from the center of conversations and amplifying voices of local collaborators [12]. Mentors in projects such as the EN-QI ECHO can work with trainees to recognize that in large projects one’s role may be primarily supportive, whereas in other projects their role may be more central. In our study, both enhanced pre-project discussion of the scope of the fellow role and facilitating ongoing opportunities to debrief about virtual partnership challenges and strategies may have been helpful for participants.

This study is not without limitations. First, while the involvement of fellows was intentional and thoughtful, the EN-QI ECHO was not designed as an instructional program for fellows interested in global health. As such, metrics such as knowledge acquisition or performance, as measured by the Accreditation Council for Graduate Medical Education (ACGME) during fellowship[42, 43], were not included in the study design. Second, only fellows from US NPM programs were involved. We can therefore only comment on how the EN-QI ECHO model served US fellows. Third, we did not elicit feedback from the Ethiopian coaches about the fellows’ involvement in the project. Understanding how the Ethiopian coaches viewed the fellows, their communication, and their sharing of knowledge would have been valuable information that could allow us, and other programs, to refine the fellow role in similar future projects. Fourth, focus group feedback was only able to be obtained from half of the fellow participants. While the four fellows shared a range of positive and negative comments, their views may not represent the views of those who did not participate in the focus groups. Lastly, this study involved eight fellows from the same specialty involved in a single project. While we feel that many of the themes and lessons from our work could be applied to other virtual settings, it is not clear if the experience of our NPM fellows can be generalized to other specialties or partnership models.

Conclusion

We demonstrated a virtual partnership model can include fellows in a low-cost and high value approach to global health work. The EN-QI ECHO project was well-liked and highly valued by fellows as a meaningful training opportunity. Reflections on what could be improved were carefully considered and balanced with pragmatic views regarding the context of the project. Future work should focus on models of fellow pre-participation orientation and goal setting for virtual projects and how to track fellow performance. Concurrently, educators in HICs and LMICs should prioritize the equitable engagement of trainees from host and partner countries. Overall, the NPM fellows engaged in EN-QI ECHO agreed that project ECHO is a valuable model to deliver just-in-time training and education in global health.

Author contributions

SR, DE, BW, and DE conceptualized the study. SR, CC, and JJ performed the data analysis. SR, CC, ED, AJ, SG, JW, OB, AH, ZS, ASJ, CL, BK, BN, KT, DE, CB, BW, and JJ drafted or revised the manuscript, approved the final version, and agree to be accountable for all aspects of the work.

Funding

This study was supported by the American Academy of Pediatrics (AAP) through a grant from the Laerdal Foundation and complemented by funds from the AAP Section on Neonatal-Perinatal Medicine. AJ and JJ receive support from the National Institutes of Health (R21HD110817 to AJ; K23HD100594 to JJ).

Data availability

Data generated during this study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was approved by the institutional review board of the American Academy of Pediatrics (Chicago, IL, IRB #23EM01). Final protocol and procedures were approved by the Ethiopian Pediatrics Society. All methods were performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all fellow participants who completed surveys and/or participated in focus groups.