Helping Babies Survive: Lessons Learned From Global Trainers

To estimate the total global reach of the HBS program, we first obtained equipment distribution data from Laerdal Global Health, co-creators of the program, who manage the materials and are responsible for all equipment orders. We then examined HBS material download data as of March 2020 from the HBS Web site, which included facilitator flip charts, provider guides, action plans, and parent guides in pdf format.

To understand the lessons learned from HBS trainers, we examined 3 pieces of data available on the HBS Web site (hbs.aap.org). Data were examined by using content analysis, a two-phase process of reviewing data to identify and derive meaning from the text. Using publicly available information from the HBS Web site, the research team analyzed data collected over the 10-year history of HBS. The study was focused on areas of the HBS Web site where trainers share information about their experiences conducting HBS trainings, including a database, “Stories from the Field,” and a forum to share tips to “Know Before You Go.”

The first phase in this iterative, data-driven process consisted of open coding to identify categories that occur in the data. In this phase, the research team reviewed the largest source of data on the HBS Web site, a basic database (hbs.aap.org/Record) where site visitors can view the historical log of HBS trainings from trainers around the world. The self-reported data collected in this database include various aspects of HBS trainings, such as date and location of training, numbers of individuals trained, and a field for entering lessons learned from the training experience. The database contains hundreds of entries, which offered an opportunity to examine a broad range of data points.

Using themes identified in the first phase, the research team used thematic coding in the second phase to analyze narratives and first-hand accounts reported in “Stories from the Field” (hbs.aap.org/Stories) and the “Know Before You Go” forum (hbs.aap.org/Know). “Stories from the Field” is a collection of first-hand narrative accounts of training experiences submitted by HBS trainers and provides readers with an in-depth depiction of the training experience. Similarly, the “Know Before You Go” forum of the HBS Web site contains robust first-hand lessons learned and offers tips and tricks to readers planning HBS trainings of their own. Submission forms for both of these forums include the following prompts:

• What worked best for your course?

• What did not work well for your course?

• Can you name one completely unanticipated challenge you faced and how you were able to overcome it?

• What advice would you offer others implementing HBS programs in the field?

• What is one thing you would have done differently?

Using material distribution data from Laerdal, >1 million pieces of HBS equipment have been circulated worldwide as of March 2020. This includes 173 591 simulators (NeoNatalie, PreemieNatalie, and MamaBreast), 56 448 flip charts, 113 608 action plans, and 744 260 provider guides (Table 1). Using these data, we estimate 850 000 providers have been trained worldwide. It should be noted, however, that this is a conservative estimate and likely underestimates the total number of providers trained because simulators are generally re-used for multiple trainings, and written materials are often downloaded from the Web site and printed in-country rather than being ordered.

Using data from InternationalResources.aap.org as of March 2020, we found that HBS materials were downloaded 134 477 times. The majority, 114 617 (85.2%), were for HBB materials, 15 963 (11.9%) were for ECEB materials, and 3897 (2.9%) were for ECSB materials (Table 2). Combining data from Web site downloads, courses taught, and distribution data, HBS has reached 158 countries and has been translated into 27 languages (Fig 1).

By using the HBS training database in the first phase of the qualitative analysis, 3 major themes critical to building sustainable HBS programs were identified: support, local context, and planning (Fig 2). From the information provided by HBS trainers, success in teaching HBS required recognition of these 3 necessary components. Implementation of the program required not only teaching the HBS modules but recognition that significant work and planning is needed to be accomplished both before and after teaching the actual workshops. Subthemes identified emphasized the importance of (1) having local contacts initiated before training; (2) communication with local health care systems and in the local language; (3) frequent and sustained hands-on practice during and after the course; (4) demonstrating success to the learners; (5) ensuring appropriate language is used, taking into account provider literacy; (6) identifying gaps in knowledge or care within the local health system; (7) having adequate time for training; (8) being able to deal with unexpected challenges in-country; (9) adapting to changing situations; and (10) ensuring the proper supply of training materials.

The second phase of the qualitative analysis added examination of the “Stories from the Field” and the “Know Before You Go” sections of the Web site. Overall, the majority of the trainers were from the United States (60.1%), with 39.9% based in other countries. All 3 sources of qualitative data represent implementation in a variety of countries (Table 3). Using these data, we were able to provide further definitions and examples for themes and subthemes identified in the first phase. We also selected the most illustrative quotes from the “Know Before You Go” section (Table 4).

HBS has been shown to be an effective educational method to train birth attendants worldwide in newborn resuscitation and care. Implementation science is the study of how evidence-based programs can be embedded to maximize successful outcomes.¹¹  We used this framework to help identify whether HBS trainers had successfully implemented best practices to train birth attendants. However, as implementation science and feedback from HBS trainers would indicate, teaching the course alone is not sufficient to sustain change in practice and improve care.⁸  Recent research in implementation science has identified the components for successfully implementing any new program, and we can use these scientific underpinnings to further hone our ability to reduce newborn mortality from asphyxia, infection, and prematurity using HBS training.¹² 

Support is one of the major themes identified by HBB trainers. This can be broadly defined as any effort intended to facilitate the successful implementation of and adherence to the planned, or newly introduced, HBS project. Within the broader theme of support, 3 subthemes were identified: local contacts, communication, and hands-on practice. Trainers identified local contacts as crucial not only to the initial introduction and preimplementation phase of the program^13,14  but also to ensure the training runs well at the time of delivery and that the project is sustained long-term. Specifically, contacts that were identified as being vital were the in-country Ministry of Health (MOH), hospital leadership, and “local champions”: providers and leadership in the hospital or health center who believe in and support the program. Hospital leadership, for example, can ensure that participants have protected time off so they are able to fully participate in the educational sessions.^13–15  It is also helpful to formally identify implementation leaders who will take responsibility for the implementing of the project and who come from within the target organization.¹⁵  Engaging stakeholders, local ownership, identifying a champion, and ensuring that the program is aligned with the organization’s objectives are key factors in achieving sustainability.¹⁶ 

The second subtheme, related to local contacts, was communication. This refers to any dialogue with participants and partners both before and, importantly, after training to provide coaching, supportive supervision, and quality improvement (QI) follow-up. Several trainers in this study emphasized the need to leave participants with a concrete plan as to how they will continue to practice their skills in local facilities. Having a plan for the postimplementation phase¹³  is critical for the success of any program because successful implementation can take between 2 and 4 years.¹⁷ 

Third, there is the subtheme of hands-on practice. This is at the core of the HBS programs, and many of the facilitators emphasized how useful and important this is. Hands-on practice applies not only to the sessions, when participants may be introduced to simulated practice, but also afterward for ongoing low-dose, high-frequency (LDHF) practice. Both HBB knowledge and skills have been shown to deteriorate over time.^18,19  LDHF practice²⁰  and quality improvement initiatives²¹  are critical for skill maintenance. Long-term continuous quality improvement, combined with LDHF practice, has demonstrated significantly increased perinatal survival.²²  In published studies, participants from multiple countries have stated they value the hands-on approach HBS programs provide.^5,9  Making learning dynamic and interactive is a known strategy to integrate implementation science principles into practice,¹²  and mixed interactive and dynamic education are more effective than either one is alone.²³ 

The second broad theme identified by HBS trainers was local context, referring to any of the characteristics of the local environment that influence implementation or sustainability. The most important subtheme here is gaps in knowledge or applied practices that obstruct implementation or sustainability. There is overlap with the themes of support and planning, and it is critical to assess gaps and barriers in the clinical setting. For example, after 3 years of a well-supported and well-planned scale-up of HBB training in Malawi, 13% of facilities still lacked soap for hand-washing, almost one third did not have a resuscitation area for the infant or a posted HBB action plan, and 17% did not have an infant bag and mask to use their new skills for infants not breathing at birth.²⁴  Several examples, like the above, were brought up by HBS trainers in which providers received great training, such as HBB, but then returned to a facility with no resuscitation equipment to put their skills into practice and/or no practice equipment or designated newborn resuscitation practice area (a “practice corner”) to enable them to maintain their skills. In either case, no behavior change is likely to take place, and in as little as 6 months, resuscitation skills will have declined.¹⁸  However, if providers are empowered by the training and introduced to quality improvement as a means to generate change, they can do their own gap analysis and create their own solutions.

In-country training venues, cuisine, endemic or epidemic disease, unexpected holidays, and local customs were all brought up by HBS trainers as challenges to successful training, most commonly for Westerners who arrive in-country to implement or teach. These comments from trainers highlight the need for conscientious and, importantly, culturally aware preparation for Western trainers. There may also be ongoing issues that frustrate the efforts of local trainers and champions to build capacity or perpetuate training. Some of those noted by trainers were change in personnel within the MOH or partner organization, elections, civil unrest (revolution in Nicaragua 2018), natural disasters (earthquake in Nepal 2015), and terrorism (Boko Haram in northeastern Nigeria).

Another local context subtheme highlighted by this study was language, and how being able to use training materials in the native language and teach in that language is central to success. Also encompassed in this subtheme is the challenge of illiteracy, which required trainers to focus on creative solutions, even with the highly pictorial learning materials in HBS.

Finally, local context also incorporates the need to “win over” reluctant participants or, more importantly, skeptical stakeholders noted by HBS trainers. Often reluctant participants will be convinced by the strength of the teaching methodology, simulation-based hands-on learning, and the enthusiasm of their peers and colleagues at the training. Inviting stakeholders, particularly those from the MOH, to observe or participate in the training can be enough for them to “catch the vision.”

We also evaluated the third broad theme of careful planning before teaching and implementing HBS in-country, as well as planning for sustained implementation and skills after the training. First of all, having equipment (simulators, bag and mask ventilators, suction devices) and materials (flip charts, provider guides, and action plan) is critical for successful teaching. Several of the HBS trainers encountered difficulty with the ordering and delivery of equipment and materials in a timely manner. Issues encountered included the cost of the equipment for many poor countries or programs with minimal financial resources. There was also difficulty in having the equipment clear customs and arrive to the teaching sites in sufficient time for the learners to become familiar with the educational content before the training. Access to the equipment after the training was also an issue noted by the trainers. Developing a plan with the local contacts to ensure delivery and other help in this aspect was noted to be invaluable.

Pre-planning with local medical leaders and ministries of health was critical for the success of the course and training. The time spent planning assured that providers were available for teaching, and that a plan for sustaining the material learned at the local level was in place. Several of the HBS trainers noted that without the involvement of local leaders, it was extremely difficult to implement the program.

Several of the trainers emphasized the need to “plan” for the unexpected. In addition, having flexibility during the training and adapting to unanticipated challenges helped to assure success of the course. Unanticipated challenges included such things as learners arriving late to courses, shortened teaching time, language and translator challenges, and requests for alternate courses to be taught. Others mentioned difficulty connecting to the Internet needed for teaching, limited local resources or medical supplies, and not having sufficient equipment to train or for use after the course.

Finally, a major focus of implementation science, and as noted by HBS trainers, is the need for planning sustained integration of new knowledge and skills after the initial training.^13,15  Several studies have shown that frequent and continued review of educational material and practice of clinical skills was important for sustained change after the trainers left the country or local site.^20,22  Several HBS trainers emphasized the need for having a succinct and manageable plan for making sure that the skills learned continued to be practiced and for reinforcement of the medical knowledge. As noted above, without a plan for continued skills practice and team building at the local site over the following weeks to months, these best practices for resuscitation would not be sustained and improvements would not occur. It was clear that without this step, the new interventions would not be as successful and previous practices would prevail. Helping to plan a quality improvement process was also noted to ensure success. By implementing a plan to measure and record processes and improvements, the local team could document better outcomes and share their success.

Although the current study is the first we are aware of attempting to gather lessons learned from the large cohort of global HBS trainers, our data are limited to the comments of those trainers who self-selected to record their trainings in the HBS database or forward comments to “Stories from the Field” or “Know Before You Go.” Our data represent only a portion of the many HBS trainings conducted in the last 10 years. Although trainers based outside the United States are well represented at nearly 40%, responses were weighted toward US-based trainers (60%). We favor increased efforts to connect international trainers to the American Academy of Pediatrics and to each other to gain a deeper perspective on successful, sustainable training worldwide.

The past decade has been highlighted by widespread distribution of HBB programming, with helpful feedback provided by those who have facilitated trainings. We have identified important lessons learned, with respect to what has been successful in teaching and implementing as well as challenges and obstacles faced. Using implementation science to further integrate HBS into newborn care throughout the world will ensure continued uptake of new resuscitation skills and improve neonatal morbidity and mortality in the next decade of HBS.

We thank Sabrina Kernerman for her assistance in editing.

ECEB

Essential Care for Every Baby

ECSB

Essential Care for Small Babies

HBB

Helping Babies Breathe

HBS

Helping Babies Survive

LDHF

low-dose, high-frequency

LMIC

low- and middle-income countries

MOH

Ministry of Health

QI

Quality Improvement