Nidhi Lal, MD, MPH, Larry Leeman, MD, MPH NAVIGATING ORGANIZATIONAL, POLITICAL AND CULTURAL CHALLENGES IN A MULTI-CITY ALSO TRAINING PROGRAM IN INDIA Nidhi Lal, MD, MPH, Larry Leeman, MD, MPH Navigating Organizational, Political and Cultural Challenges in a Multi-city ALSO Training Program in India Special thanks to Ann Evensen, MD Joel Henry, MD

Learning Objectives Understand the diverse nature of organizational and cultural challenges in India Create strategies to anticipate logistical problems and recognize when alternate plans are necessary List means of adapting a course to fit local needs while maintaining high standards for training and application of skills.

Maternal Mortality in India- WHO DATA

Locations NEW DELHI SHIMLA HYDERABAD CHENNAI

India Map

City New Delhi Shimla Hyderabad Chennai Total number of participants 31 28 35 42 # of students passed on first try 19 4 24 21 # of students passed after remediation 1 2 8 #of students Failed after remediation 6 7 13

New delhi Good teaching facility- A Simulation Center Faculty included Local as well as International ALSO certified Instructors Ob residents attended the course Smoothly run sessions due to planning done well in advance and local learner base Language was not a problem

New delhi

New Delhi

SHIMLA In the foothills of the Himalayas Faculty included Local and International ALSO instructors Weather challenging in winter months Learners had to travel long distances to attend course

SHIMLA Several learners were non Ob and non MD providers which made it challenging for learning to occur Language was a concern for the nursing and non MD providers- some explanation was done in local language – Hindi Course recommendations were adjusted to involve locally available technology – eg- CT scan not always available- use clinical judgement, ultrasound, fetal monitoring not readily available

SHIMLA

SHIMLA

SHIMLA

SHIMLA

Hyderabad Course taught in a local teaching hospital Faculty included Local and International ALSO instructors Learner base – very strong Convenience of attending Well planned sessions Language not a concern

HYDERABAD

HYDERABAD

STATISTICS

Challenges encountered Most Participants were not practicing Ob providers- ALSO must be limited to Ob providers and if unable to have enough registrants- consider changing to BLSO or rescheduling. Language was noted to be a barrier to several midlevel providers- RN’s. As several ALSO instructors were fluent in Hindi – we were able to translate and answer questions in Hindi- however participants were often noted to be reluctant in requesting translation. It was also noted that few participants were not fluent in reading English and this was a barrier in their understanding materials taught to them. Logistical challenges related to transportation and vacations were encountered. Weather related transportation delays in remote areas need to be factored in. Facilities may not have adequate large and small group work space, especially if ALSO/BLSO class sizes are larger.

successes We were able to complete entire syllabus and workshops with translation on time. Were able to recognize translation concerns and address them as instructors were bilingual. Participants with MD background and expertise were noted to complete all skills assessment and certified- for example Obstetricians did well Challenges due to weather related unpredictability and road conditions in conducting training programs in northern remote areas in winter were recognized and future courses will be scheduled accordingly.

SUCCESSES We were also able to recognize resource limitations – understand practices - and make recommendations accordingly. Several physician learners requested additional skills workshops - leading to Recommendations - to consider a 3 day ALSO course with the additional advanced workshops and perhaps ultrasound for Ob providers Excellent Local instructors were observed teaching and certifying ALSO candidates.

LESSONS LEARNED 1- Qualified and well suited learners had a good educational experience and requested training in more advanced skills. 2- Political inclusion of non- qualified students decreased the overall experiences of learners and instructors. 3- Anticipating and addressing language, cultural and weather challenges are essential.