Nigeria has the second largest HIV epidemic in the world and is one of the countries with the highest rates of new pediatric infections in sub-Saharan Africa. The country faces several challenges in the provision of healthcare services and coverage of Prevention of Mother to child transmission of HIV. In the Nigeria’s Department of Defense, prevention of vertically transmitted HIV infections has been given a boost by utilizing Mentor Mothers to facilitate antiretroviral compliance and retention in care. The aim of this study was to explore those processes and policies that guide the implementation of the Mentor Mothers program for PMTCT of HIV in the Department of Defense in Nigeria as no studies have examined this so far.The descriptive, qualitative research approach was utilized. We conducted 7 key informants interviews with 7 purposively selected participants made up of 2 program Directors, 1 Doctor, 1 PMTCT focal Nurse, 1 PMTCT site coordinator, 1 Mentor Mother, and 1 patient from one each of the health facilities of the Army, Navy, Airforce and the Defence Headquarters Medical Centre. Open coding for major themes and sub-themes was done. Data were analyzed using thematic analysis.Findings revealed that the program in the Department of Defense had been modelled after the WHO and implementing partners’ guidelines. Foundational Factors; Leadership; Skill acquisition; and Service Characteristics emerged as processes guiding the implementation of the Mentor-Mothers program in the DoD. These findings supported the Mentor Mother Model, which empowers mothers living with HIV – through education and employment – to promote access to essential PMTCT services and medical care to HIV positive pregnant women.We concluded that no definitive policy establishes the Mentor Mothers program in the DoD. Working with Doctors, Nurses, local & collaborating partners, and communities in which these hospitals are located, the Mentor Mothers play a pivotal role in the formation, facilitation, and implementation of the MM model to effectively decrease HIV infections in children and reduce child and maternal mortality in women and families they interact with. As documented by AVERT.org , NigeriaPrevention of HIV among key populationsHIV testing servicesElimination of Mother-to-child Transmission of HIV (eMTCT)HIV treatmentCare and support and adherence to ARVs.As indicated by the UNAIDS 2018 data , about 3These 5 components have been carefully put together as a means of tackling HIV and its related challenges in the country such as stigmatisation and access to ARVs. For instance federal and state laws restrict the disclosure of a person’s HIV status, except in extremely limited cases. This is due to the perceived stigma and discrimination against people living with HIV. In the DoD the patients right to confidentiality is guided by the ‘DoD policy HA 96–034: Request for Medical Records or Medical Information concerning HIV positive Members’. This memo discusses the confidentiality of medical information for HIV positive service members and guides care providers on matters of anonymity and confidentiality. As part of its strategic interventions, the framework also fosters an enabling environment for HIV positive pregnant and breastfeeding mothers and HIV-exposed infants to access antiretroviral drugs . The intMMs are women living with HIV who have had personal experiences in PMTCT programs (have had HIV-free babies), trained briefly on the basic rudiments of HIV and are willing to use their own personal experience to support other women and their families in HIV care. They act as mentors to diagnosed HIV positive pregnant women within the PMTCT programme to ensure compliance and retention in care . They haMuch as literature demonstrates the beneficial impact of the MM program on PMTCT globally, no structured evaluation of PMTCT or the effectiveness of its services since inception has been undertaken in Nigeria despite the high burden of MTCT of HIV , and no The objective of this study was to explore the policies and processes that guide the implementation of the MM program in the Nigeria DoD health facilities. This paper is one in a series of five (part of a PhD study) that sought to analyze the implementation of the MM program in the DoD and provides the basis for developing a framework to facilitate utilisation of MMs in other hospitals in the DoD currently not engaging them.. The manuscript has been developed in accordance with the COREQ Standards for Reporting Qualitative Research.The descriptive exploratory qualitative design as described in Howitt & Cramer  was utilThe research was conducted in selected health facilities of the Nigerian Army, Navy, Airforce, the Defence Headquarters Medical Centre (DHQ), and the HIP headquarters in Abuja. Abuja, the Federal Capital Territory (FCT) administratively assumes the status of a state with its own minister who is equivalent to a governor in any of the 36 states. Abuja is in the north central part of Nigeria (middle belt region) and is home to the headquarters of the Nigeria’s DoD with well-established health facilities providing HIV/PMTCT care. The MODHIP coordinates all military HIV programs in Nigeria and is responsible for policy decisions/research in HIV medicine in the Nigerian military. The DHQ Medical Centre acts as the administrative Headquarters and oversees all PMTCT programs in the Nigeria DoD health facilities.Appointments were made with the directors and heads units for the purpose of obtaining permission to access participants and conduct interviews. JMI paid several visits to the proposed participants to get familiaised with them, explain the nature of the research and to gain their cooperation to participate in the study. The maximum variation sampling strategy was adopted for this study. Twelve participants were proposed for the study but due to the contextual nature of the Nigerian military, access to the facilities by non-staff was restricted therefore JMI had controlled access to most participants particularly those at policy level. That accounted for the (seven) number of participants who were eventually chosen from one each of the military health facilities of the Army, Navy, Airforce hospitals, the MODHIP and the DHQ Medical Centre in Abuja.The participants were purposively selected based on availability, choice to participate in the study and capacity to enhance understanding and exploration of the research question. A well-informed and experienced MM was recruited to facilitate access to the participants. They were approached face to face initially and informed that the research was for the purpose of obtaining a doctoral degree by JMI. Thereafter, leaflets describing details of the research were presented to them and opportunities given to them to discuss the research topic. Subsequent visits were then made to the participants to obtain their consent to participate in the study. Their training, wealth of experience in HIV/ PMTCT care and roles in the MM program were considered for participation in the study. All participants were recruited over a one month period following the initial engagement. Eligibility for inclusion in the study was first the willingness to participate, a minimum engagement period of six months in the MM program either as a patient, care giver or administrator (program director). None of the seven participants selected withdrew from the study.Of the seven participants, three were male while four were female. They were significant stakeholders in the DoD MM project being that they were all engaged at different levels of the program. The program directors specifically are responsible for policy decisions regarding the MM program and coordinate MM program activities and all HIV/PMTCT services in all the armed forces hospitals across the 36 states in Nigeria. In conjunction with the United States DoD under the Walter Reed Programme, the directors formulate policies, recommend, recruit and train MMs, Doctors, Nurses and other key team members in PMTCT care, as well as supervise the various PMTCT sites in all the armed forces hospitals in the DoD. The Nurses act as focal persons . The Doctors provide consultation for all PMTCT patients on a one-on-one basis and treatment options are explored based on each client’s needs. The site coordinators man the various PMTCT centres and also recommend MMs who have successfully benefited from PMTCT in the various DoD hospitals and living healthy for employment. These MMs are considered as good examples to newly diagnosed HIV positive women to aid retention in care. They also complement the healthcare workforce and serve as strong linkages between health care providers and peer support networks. The rationalization of these participants’ personal experiences and the DoD operational activities were employed as a means of harnessing data to understand the processes governing the implementation of the MMs program within the DoD health facilities..The semi-structured interview guide for this study was developed by the researcher, guided by “The WHO Health Systems Responsiveness Key Informant Questionnaire (2000),” the “Key Informant Survey (2001)” and “The Health system performance assessment  tool” after conducting literature review –29. It cApproval to conduct this study was obtained from the University of KwaZulu-Natal (UKZN) ethical review committee (protocol number 00000186/2009) and the Ministry of Defense Health Research Ethics Committee (MODHREC) (reference number MODREC/APP.312/122/0/7/20/1/9). The Nigerian Ministry of Defence (MOD) operates a joint partnership with the United States (U.S) DoD/Walter Reed Program to provide HIV research and prevention services in the Nigerian military. We observed standard protocols as stipulated in the Helsinki declaration to ensure confidentiality and anonymity of participants throughout the data collection and analysis processes. As much as possible, we made sure our views did not influence our interpretation of the participants, as we did not superimpose our personal understanding of the issues discussed with them.After obtaining gatekeeper permission from the MODHIP, a research assistant was engaged to facilitate identification of`participants and schedule interviews. Participants were informed that taking part in the study was voluntary and that they may choose to withdraw at any point in the research process without any consequences attached. Researcher reflexivity was taken into account in this study. JMI is a nurse with many years of clinical practice to her credit who had interacted severally with HIV clients. However, this interaction and knowledge did not interfere with the process of data collection or influence the report of findings that emerged from the study in anyway. JMI detached herself from the study to objectively identify areas of influence in the study to avoid potential influence on the study process . As part. Measures to ensure rigor were adopted throughout the study. Data were member-checked with participants to verify accuracy at the end of each interview session. Bearing this in mind, field notes were utilised (to keep track of important aspects of my conversations with the participants). Verbal and non-verbal cues were also taken during the interviews to inquire, discuss and explore the research question. These were used during analysis to better interpret the results. Transcribed data were anonymized and reviewed with audio recordings for consistency and accuracy.All interviews were conducted by JMI (the researcher) who is an experienced Registered Nurse currently undertaking a clinical doctoral research but not directly involved with care provision in the MM program. Before each interview, written and verbal informed consents were obtained from the participants and at their choices, the interviews were conducted in their offices during lunch breaks and free from distractions. The one patient (participant) agreed to have her interview in the hospital’s conference room on a day chosen by her. The interviews which lasted between 30–45 min each took the form of an open conversation and were audio recorded with the participants’ permission. Despite the heterogenous predetermined sample size, data saturation was observed among the different cohorts of participants as they all had the same (good) knowledge about the DoD MM processes. All interviews were conducted in a detailed and consistent manner over a period of six weeks. There were no repeat interviews for this study. The research assistant was also present during the interview sessions. Finally, the findings were cross-checked with the participants to ensure that the results were a true reflection of their views. This also improved the trustworthiness and strengthened validity.In order for the participants to contribute meaningfully during interview sessions, we attempted to establish trust with them by repeated visits to the participants and reemphasizing that participation in the study was voluntary. This was demonstrated in the opening moments of each session by indicating that the study was for academic purpose only and also encouraging them to express their opinions freely. Utilizing the purposive sampling strategy in this study ensured an adequate spread of participants from the facilities selected. To increase trustworthiness, the research process was described in detail, data was coded and compared with relevant literature to enable its replication in other settings when required. To ensure dependability, a detailed documentation of the reflections of events observed during the data collection period was done. An audit trail (to ensure that the findings were based on the participants’ responses) was utilised to describe the research steps up to the presentation of findings. This was to ensure consistency and stability of the data over time and under different conditions By rechecking the emergent themes generated from the data and comparing the data with similar research findings confirmability was assured. The coding list was then updated (deductively) in order to accommodate all emerging themes until a saturation point was reached, implying that no new themes would emerge. The codes were then reviewed independently by JMI and analyst and necessary changes made. This was to ensure inter-coder reliability.A reflexive thematic analysis technique using an inductive approach , 31was u. The participants’ quotes are presented to illustrate each theme and identified by their pseudonyms. Fig. On completion of coding, similar or related codes were grouped into categories and the categories grouped into themes, which were used in interpreting and reporting the findings. The correlation between each of the themes was identified which explored the views of the participants on the policies and procedures guiding the implementation of the MMs program for PMTCT of HIV within the DoD health facilities. The TA technique , 32 demoThe categories which emerged included foundational factors; leadership; skill acquisition; and service characteristics. These formed the essence for examining the processes and polices that guide the implementation of the MMs program in the Nigeria DoD. The findings also provided insights on the resources and skills needed to successfully manage and sustain the MM program in the various DoD health facilities. The categories, themes, and minor themes (essences) that emerged from data were clearly defined and presented in the Table . Thus, as a participant in the ‘Global Plan’ on eMTCT, the Nigerian government and by extension the Nigeria DoD also recognize that women living with HIV must be at the centre of the response to the epidemic by critically playing a role in task-shifting to promote health service quality improvement as well as uptake, retention and adherence to care, hence the utilization of MMs for PMTCT services in the DoD health facilities. The foundational factors also revealed three (3) sub-themes which were crucial to the facilitation and implementation of the MMs program in the Nigeria DoD. They included guiding principles/models; PEPFAR and State funding; and partnership with the national health system.The foundational factors comprised of those policies and processes supposedly guiding the implementation of the MM program in the DoD. This theme emerged through asking some of the stakeholders if there was any document(s) or Act establishing the MMs program. Relevant literature suggested that the National Strategic Framework 2014–2021 and the WHO Global Plan played a major role in the implementation of the MMs program in the Nigeria DoD. The initiative aimed at achieving Zero new infections, zero AIDS related deaths and stigma . While tIf we are to talk about documents, that was what came up from the World Health Organization. we leveraged on it and together with other implementing partners, we adopted it. (Director B).As I said there is no one document I can pin-point to except from the experiences I came with from ICAP which I proposed to the office and they gave me the go ahead to implement the Mentor Mother Programme (Director Y).The international mentor mother model guides us to be able to fashion out or carve out what we practice in the DoD. It is the same checklist used in accessing the progress.(Doctor).We are guided by the WHO and US DoD guidelines for PMTCT. All our trainings and program activities are fashioned along that line (Nurse).Guiding principles and models significantly influenced the implementation and shaped the MM program in the DoD , 33–37. This program started way back in 2015 when we saw the need to improve the services we were providing to the positive mothers living with HIV. We saw a gap first in tracking and the outcome of their babies. We instituted an effective tracking mechanism using people who were lay health workers on ground (Director B).From the above submissions, it was evident that there was no definitive guideline underpinning the DoD MM program therefore underscoring the fact that no direct policy or Act guides its implementation in the DoD. However, the DoD policy Document- “DoD Instruction 6485.01: Human Immunodeficiency Virus (HIV) in military service members” updates the policy for identification, surveillance, and management of military personnel infected with HIV and for prevention activities to control the transmission of HIV. Therefore the three Armed forces provide HIV prevention services for both its personnel and their families . Since tIn one of the review meetings we had with other countries from the east African sub region in Tanzania, experiences were shared….I compared ours to the program elsewhere and that is helping us make improvements (Director Y).By constantly engaging with stakeholders and other implementing partners to explore innovations in PMTCT care, the DoD management strove to expand access to patient centred HIV care for effective service delivery as cited by this participant…The program is funded by counterpart funding. The DoD brings some part which they administer themselves and the Federal Government of Nigeria makes available some part.(Director B).We have been funded through the Nigerian government in collaboration with the Nigerian Ministry of Defence and the American government through PEPFAR(Director Y).Funding was one of the foundational factors crucial to the implementation and facilitation of the MM program in the DoD as the findings of this study suggested. In this regard, a partnership exists between the U.S Military HIV Research Program/Walter Reed Army Institute for Research (MHRP-Nigeria) under PEPFAR for primary/facilitative funding sources for HIV activities (through the DoD – PEPFAR funding). The aim of this partnership was to assist the Nigerian government until such a time it eventually takes ownership of the program as the following participants reveal:Funding has crashed, you know PEPFAR funding has been dwindling over the years. Otherwise I know they would have said ‘well go ahead and expand to all the other sites’ (Director Y).When there is fund we are able to get personnel, equipment and all the logistics required to keep the program running (Director B).In addition, when asked of specific challenges facing the facilitation of the MMs program, the participants indicated that although there had been a joint partnership for funding, these funds have been largely inadequate thereby challenging the progressive implementation of the program. In the current era of gradual withdrawal of funding for HIV by international donor agencies, national governments in affected countries may eventually take over a larger portion of the costs . This isI think the leadership has been there. Whenever I seek approval to do some things to improve on the program, they allow me to do that. …(Doctor)The leadership, team support and the facilities are running smoothly. The ownership and commitment at the facilities is able to sustain the program so it would not just crash.(site coordinator).Leadership was also noted by the participants as one of the key performance indicators that influenced the facilitation and implementation of the MMs program in the Nigeria DoD. The structure of the program in the DoD made possible by a purposeful leadership adequately equipped the MMs and staff with the needed materials and skills to carry out their tasks. These participants appreciate the responsiveness of the DoD HIV program leadership:. The essences behind these three (3) sub-themes speak more on the management team, specifically the wisdom and solutions that the management of the program provided, and the team spirit of the sites’ management. These were deemed to be effective factors influencing the implementation of the program. Ensuring unrestricted access to ARVs also served to boost the health of mothers and improved reproductive, maternal, newborn and child health outcomes. Team spirit describes the feeling of loyalty, commitment and pride that exist among members of a team that keeps them committed to the team’s success. This entailed a lot of cooperation among team members. This emerged as one of the key factors influencing the MM program implementation as volunteered by these participants, although that was not without some challenges:Due to the team spirit, training and the willingness to sacrifice, our site team commanders give us a lot of encouragement to make sure that the program flourishes (Nurse).In the communities where we operate, the military commanders in the various hospitals, the nurses, every other person is very supportive. That is the spirit behind the success of this program. (Doctor).Thus, this category was associated with sub-themes such as management team support, the military factor, and team player/spiritMy problem is the program staff. some of them wait until consumables are exhausted and they wake up one morning and say there is no test kit. Then they start talking about emergency orders and the rest. (Director B).While a portion of the program’s success story was attributed to the management team (including the program staff), a director however reported some lapses:personal experiences with HIV (as in the case of MMs); training ; and data literacy. Basic educational qualification  was a criterion for employment as a (an) MM. The essence of these sub- themes was to measure providers’ preparedness, skills, and competency in their engagement in the MM program. In other words, the findings from this study revealed that to ensure the successful implementation of the program in the DoD necessitated the providers to be adequately trained. For the MMs, the most important primary engagement criteria were personal experience (women who are living with HIV) and have successfully undergone the PMTCT program [It is more of foundational training where we tell them about HIV incidence and how to avoid getting infected; the need for safe breastfeeding because of some people who mix feed, the need for adherence on their drugs and how to follow the mothers up especially those ‘lost-to-follow up (Director B).This was considered very significant in the smooth running of the MM program in the DoD. The findings suggested that the program staff acquired skills through three (3) main means:  program , in addi program  which isBasically the person must be able to read and write, so a minimum of a secondary school certificate suffices. Although we have some that are Bsc holders. In addition, the person must have a fair knowledge of HIV services, must be a positive woman living with HIV and would have gone through the PMTCT program in the sites (Director Y).First and foremost as a Mentor Mother the issue of stigma should not be in the way. It should be a woman that can come in front of other mothers and say, “I am a positive mother”.(Site manager).When asked about the criteria for engagement , 42 as aOccasionally they are brought along with the HEADS of Nursing Services in the different health facilities and they are just given a general training on HIV, at least a basic foundational training on HIV for about two days. Some of them come in here for about three days and from time to time they are still invited and updated on the current knowledge (Director B).They receive basic training about prevention of mother to child transmission, HIV testing, disclosure of results to mothers, tracking of lost clients, some elements of EID services, that is early infant diagnosis services. Those are the specific things that are captured in the curriculum we currently operate for them now (Nurse).It is both didactic and practical hands-on training especially when it requires EID services.(Doctor).Findings revealed that the DoD MMs undergo specific training on communication and counselling skills, HIV testing and counselling, PMTCT and paediatric care, adherence to HIV treatment, record keeping, training on confidentiality, infant feeding and child nutrition in line with implementation guidelines to sufficiently equip them with PMTCT skills and provision , 42–46, These narratives reveal an absence of a structured curriculum for training of the MMs as it obtains in South Africa. The MM program in the DoD being borne out of the initiative of one of the directors could be one of the reasons for the absence of a definitive policy establishing its implementation and subsequently, lack of a definitive career structure for the MMs.The training provided for the staff is good, there are already deployed staff and Mentor Mothers for the program. (Doctor).The essence of training and skills acquisition was to achieve competency in service provision by the healthcare providers, MMs inclusive. This ensured that an efficient human resource workforce was on ground in the health facilities particularly as it concerned HIV care. JMI sought further clarification on the effectiveness of these training programs for the healthcare providers. These participants said:Sometimes whenever we call them for the review meeting, we also flash on those trainings to remind them especially if there are new things introduced into the program. On the effectiveness I will say it is good because that has improved our indicators for lost- to follow up (Director Y).Staffing and wages, service quality, financial, socioeconomic and psychological support, and service satisfaction. The essences in this category included personnel contribution, services and products accessibility and service quality. The scale-up of ART and PMTCT had been some of the great successes of the MMs program in the DoD since its inception. Therefore as part of its strategic interventions, the MM program fostered an enabling environment for HIV positive pregnant and breastfeeding mothers and HIV-exposed infants to access antiretroviral drugs as substantiated by these participants:I access care with DHQ Medical center. I am very close to the mentor mother (Patient).Even on non-clinic days they still access services. If these mothers just bump into us and say, ‘I want to register’, we just attend to them.(Nurse).We run a five-day clinic, throughout Monday to Friday in this facility. There are no special days for ART clinic. They walk in and blend with the outpatients at their convenience (Doctor).Facility and service characteristics predicted access to ART, retention in care and PMTT outcomes in the health facilities and were determined by the DoD health workforce, PMTCT/ART services and quality. Findings revealed four (4) key performance indicators that facilitated the MM program and aimed at promoting healthy living . These were: We felt getting an effective tracker system using the Mentor Mothers who are themselves positive mothers has delivered in our sites… … There are nineteen of them at the moment.(Director Y).The U.S Department of Defense-Walter Reed Army institute of research partners with the Nigerian Ministry of Defense Implementation program to combat HIV/AIDS and public health challenges through training, treatment and research. (Doctor).Areas worst hit by the HIV epidemic require an ideal number of health workers who are suitably distributed across different occupations and geographical regions to ensure population coverage of health interventions , 48. HeaSome of us are graduates. The 40,000 Naira has gone a long way to help us but then our desire, dreams are far bigger than that (Mentor Mother).While healthcare workers may earn different levels of salary for instance ‘top ups’, fee-for-service, informal incomes, the DoD MMs are given a stipend irrespective of their academic qualification and period of engagement as cited by one of the MMs:We started with about N20 000 and when I presented their issues to the office, they are now paid a maximum of N40 000. We just did it as a program so as to have a unified structure for them.(Director Y).We give them some stipends to encourage them at least for their transport, for making out time to follow up on the mothers who are challenged. Some of them get as much as N40 000, whereas graduates are not even getting up to twenty thousand. So, it is really big, and for some of them who have lost their husbands, this has been a source of income…they are very happy as far as I am concerned.(Director B).The directors justify the current state of the MMs wages:They are not permanently employed; they are more of ad hoc, contract ad hoc staff. As far as the program lasts and there is funding, they will continue to exist (Director B).It would appear that definitely, the MMs exist in the DoD to fill a gap based on an existing need. Therefore when asked about their employment status, this participant described it as ad hoc:As a mentor mother you are not employed, and because you are not employed you have not tendered any certificate. I cannot tell you whether our employment is contract or casual. (mentor mother).An interaction with the MM confirmed the narrative above:Being a mentor mother is a privilege and not a right.. it is not a regular job and they are not coerced (Director B).Much as complaints such as these had attracted an increment to their stipends, a DoD program director reemphasized the status of their employment:. However, this participant reveals a role extension for the MMs despite their poor remuneration and job status:Basically, we are exposing them to also do more of tracking among people on treatment and data recording around EID services (Director Y).The above narratives underscore the lack of permanency of the MM’s employment which perhaps MMs view as a lack of supportThere are other social services beside HIV services and we’ve always encouraged patients to go to the right place to seek those services. (Nurse)Occasionally we make available little things, there is this OVC (orphans and vulnerable children’s) site where we have a program that takes care of about 250 OVCs and those ones who are out of school. We send them for skills acquisition. (Director B).Clearly, from these narratives, tracking was a focal aspect upon engagement as an MM. Interestingly, they were also trained on data recording which is a more engaging aspect of the MM system and not only affords research capacity building but also enabled the MM’s to witness how their involvement contributed more comprehensively to the programme. The DoD management also availed patients and other healthcare consumers with social support services to further build capacity towards sustaining the program:The mentor mothers program has come to be because we want to use mentor mothers to encourage other people who have these HIV challenges so that they can adhere to their treatment and other processes that are supposed to keep them and their families healthy (site coordinator).This participant explains further the existence of the MM program and its services:About 85/90% of our clients are civilians. That is just to tell you our services are very accessible (Nurse).All our services are at no costs. PEPFAR supports everything…they are very accessible. (site coordinator).Findings also indicated that access to the services within the program was extended to the civilian population as well, as cited by this participant:I think they see it that the program has worked. It has impacted them positively and they are happy. They feel the program has been worthwhile and met its goals. (Director B)I think the mothers are happy for it. (Director Y).The mothers see it as a welcome service and these services have actually improved their engagement with the facility. (Doctor).Quality determines the extent to which a product complies with a set standard. The core of the MM program was the ability of the health system to enhance performance standards and draw attention to and strengthen areas of weakness to expand access to anti-retroviral therapy with positive outcomes for both mothers and babies. To achieve this, trained MMs within peer group settings provide individual support for HIV-positive pregnant women and postpartum mothers to help them address unmet needs for understanding HIV, self-care, infant care, psychosocial support, and acceptance, and meeting economic needs over the longer term , 49. On rom my own assessment I will say to a reasonable extent they will give it a pass mark (Mentor Mother).FWe have more people being retained in our care now compared to what it used to be (Nurse).“The program has helped some of us live well” (patient).These views were summarized by these participants:The current study critically explores the processes and policies guiding the implementation of the MMs program for PMTCT of HIV in the Nigeria’s DoD and highlights the core components, resources and skills needed to realize organizational goals. Previous studies indicate that although the MMs program is not legally supported by policy in the country, the MM initiative for PMTCT exists in Nigeria since 2007 currently guided by the National HIV/AIDS Strategic Framework . In anot. Here the MMs receive training on basic communication and counselling skills, PMTCT, record keeping, confidentiality, infant feeding and child nutrition and must work under guided supervision. They are equally handed stipends which are barely enough to take home.The findings from this study revealed that the DoD MM program was also an initiative of one of the directors (director Y) in 2014. According to director Y, he proposed some of the ideas he came with from ICAP to the DoD management and was given the ‘go ahead’ to establish the MM program. Data made available by the Nigerian Military HIV Research Program  indicate. Similarly, available records indicate that the last comprehensive assessment of the DoD MM program was conducted 2017. The unavailability of progressive evaluation was unanticipated and reflected the lack of a definitive monitoring and evaluation blue-print for the MM program in the DoD. In the same vein, Oleribe & Enenche [Gureje et al. and Ubochi et al., , 51 draw Enenche  lament tThe current study having examined the MM program in the DoD revealed 4 institutional categories  which formed the bedrock for the initiation and running of the program, even as no definitive policy governing its implementation exists (in the DoD). Hence, the findings from this study support the mothers2mothers’ Mentor Mother Model, which empowers mothers living with HIV – through education and employment – to promote access to essential services and medical care to other women . Just liTo begin with, the interviewer (JMI) had controlled access to the military health facilities to access the participants. Perhaps the highly regimented and intelligence guarded nature of the Nigerian military was responsible for this and contributed to the limited sample size. A well-informed/experienced research assistant in one of the health facilities was recruited to facilitate access to the health facilities and participants. Much as information about HIV is available in the public domain, research on engaging MMs for PMTCT in the DoD is limited because there is a non-disclosure policy on HIV matters in the military except where absolutely necessary. This probably accounted for the participants’ exercise of caution with volunteering certain information particularly when it had to do with policy. Although they had been assured that this study was strictly for academic purpose, the use of a tape recorder during the interviews may also have added to their exercise of caution.It was therefore challenging to get most of the participants to provide detailed information on some critical aspects of the MM program implementation and sustenance. This leaves the potential for the views and perceptions of the major stakeholders at policy/implementation levels to be missing in this study. Again, due to the dearth of previous published works on the MM implementation in the DoD, generalizability could not be made of the findings of this study. Despite these limitations however, various measures to ensure rigor were adopted throughout the study. Field notes were used (to keep track of important aspects of my conversations with the participants). Verbal and non-verbal cues were also taken during the interviews to inquire, discuss and explore the research questions. The exploration of the policies and processes guiding the implementation of the MM program in the DoD highlighted critical implementation gaps. Findings (which were member-checked with participants to verify data accuracy) were based on participants’ views as evidenced in their reported direct quotes. A strength of this research is in the design and the variation in the sample which comprised of different cohorts and allowed for the exploration of a broad spectrum of complexities while also allowing a deeper understanding of the novel MM program in the DoD. Details of this study are also presented so that the study could be replicated. As a high HIV burdened country, Nigeria is yet to cover much ground in its journey towards elimination of MTCT (eMTCT) of HIV. The MM program for PMTCT is one of those strategies by which target achievements for eMTCT could easily be attained. The DoD management could therefor contribute towards achieving the 90–90-90 goals (even in 2022 presently) for pregnant and postpartum women in Nigeria through collaboration, training, and funding for research.This study has explored the policies and processes that govern the implementation of the MM program and concluded that no definitive policy exists either in Nigeria or the DoD that establishes the MM program. Some of those processes that have in one way or the other shaped the MM initiative in Nigeria and by extension the DoD support the Mentor Mother (MM) Model which promotes access to essential services and medical care to HIV positive women and their babies. In the DoD, the program has not been without some challenges which bother majorly on funding and sites maintenance. Data revealed that not all the sites in the DoD were covered by mentor mothers. However, the critical implementation gaps identified could mitigate the achievement of the 90–90-90 goals for pregnant and postpartum women in Nigeria even as others have surpassed .The peer mentorship strategy for PMTCT is a laudable initiative and requires a more formalized, well-defined position that is responsive to the needs of recipients to properly position it in the national health system as suggested by Ubochi et al. . Further


A lack of educational continuity creates disorienting friction at the onset of residency. Few programs have harnessed the benefits of coaching, which can facilitate self-directed learning, competency development, and professional identity formation, to help ease this transition.To describe the process of training faculty Bridge Coaches for the Transition to Residency Advantage (TRA) program for interns.Nineteen graduate faculty educators participated in a coaching training course with formative skills assessment as part of a faculty development program starting in January 2020. Surveys  and a focus group  were conducted to explore the perceived impact of the training course on coaching skills, perceptions of coaching, and further program needs during the pilot year of the TRA program.Faculty had strong skills around establishing trust, authentic listening, and supporting goal-setting. They required more practice around guiding self-discovery and following a coachee-led agenda. Faculty found the training course to be helpful for developing coaching skills. Faculty embraced their new roles as coaches and appreciated having a community of practice with other coaches. Suggestions for improvement included more opportunities to practice and receive feedback on skills and additional structures to further support TRA program encounters with coaches.The faculty development program was feasible and had good acceptance among participants. Faculty were well-suited to serve as coaches and valued the coaching mindset. Adequate skills reinforcement and program structure were identified as needs to facilitate a coaching program in graduate medical education. A lack of developmental continuity between undergraduate (UME) and graduate medical education (GME) creates disorienting friction at the onset of residency training ,2. An abDevelopmental trajectories in GME are unique, based on the strengths, weaknesses, and clinical experiences of each physician, as well as the sociocultural context of their learning environment. A one-size-fits-all approach is inadequate to address the individual needs of learners . Yet, moOver the past decade, coaching has been identified as a means to facilitate self-directed and individualized learning, competency development, and professional identity formation in medical students – all attributes that would also help interns better navigate the transition to residency . Unlike To date, few residency transition programs have harnessed the benefits of coaching to address the needs of graduating students and interns ,13. FurtIn 2019, clinician-educators and medical education researchers at the New York University Grossman School of Medicine (NYUGSoM) received a five-year grant through the American Medical Association’s (AMA) Reimagining Residency Initiative to establish the Transition to Residency Advantage (TRA) coaching program. The TRA program was designed to match incoming residents from five collaborating residency programs  with a Bridge Coach from their department, whom they would work with throughout the first year of residency. Each program selected the coaches based on their individual faculty and structural considerations. Coaches filled a variety of other roles in education, including associate residency program director, transition to residency program director, resident mentor and clinical educator. A structured curriculum was developed, which defined a schedule for coaching and set the agenda for each coaching session.Bridge Coaches were assigned to their first group of interns on Match Day 2020. Between the AMA grant and matching funds from the institution, coaches had 0.1 full-time equivalent (FTE) support for their coaching activities with the expectation that they would have roughly ten assigned coaches. The actual number of coaches per coach varied between residency programs (range = 1–18) depending on program factors, such as class size and the dedicated time faculty had for coaching. In programs where faculty had less dedicated time, incoming interns were assigned to a group of Bridge Coaches.The study of this program is a mixed methods analysis of assessment data, surveys and focus groups with coaches. All methodologies used to evaluate the TRA program were approved by NYUGSoM’s Institutional Review Board (protocol i19-01065).A faculty development program was created to provide coaching training to established UME and GME educators and develop them into TRA Bridge Coaches. In 19 January 2020 faculty participated in a synchronous, in-person coaching training course comprised of ten sessions . The curriculum covered coaching fundamentals, techniques and resources to foster learning and growth, and TRA program specifics . Emphasis was placed on learner-centeredness, comprehension of the specific needs and challenges of interns, and reflective thinking on how coaching can fit and be impactful within GME.A Group Objective Structured Coaching Evaluation (GOSCE) was utilized for formative assessment of faculty’s coaching skills. Faculty engaged in group role play with standardized learners and participated in a debriefing session. Observational data were collected by peer and resident observers using a structured, behaviorally anchored grading rubric see  designedThroughout the TRA program year, Bridge Coaches participated in monthly, hour-long virtual meetings led by the TRA program co-director for continuation of skills development and support of the TRA program. Coaches have the opportunity to review practical questions related to the program’s curriculum and activities and discuss coaching challenges with peers.A detailed outline of faculty development program activities is provided in the In November 2020, a virtual focus group was conducted to learn about faculties’ coaching experiences thus far. The focus group was facilitated by one of the authors (CG), who was not directly involved in the curriculum, and lasted about one hour. Semi-structured questions were used to explore participant’ opinions and perceptions of coaching – particularly in regards to what felt novel or challenging – and how they had incorporated coaching into their interactions with learners. Audio from the focus group was recorded and sent to a third-party company for transcription and de-identification.12 Along with session attendance, this data was utilized to assess feasibility and acceptance of the curriculum. Skills were assessed using Likert-type and open-ended survey questions in three competency domains: 1) Coaching Process and Structure; 2) Relational Skills; and 3) Coaching Skills.Between June and July 2021, coaches were asked to complete an online survey assaying the perceived impact of the faculty development program curriculum on core coaching skills identified from Wolff et al.’s five-domain competency framework for coaching in medical education.The focus group transcript and written survey responses were independently reviewed by AFW and CG using simple content analysis. Main themes and subthemes were identified and differences between reviewers were discussed until consensus.Participants attended an average of 8.7 out of 10 training sessions (SD 2.1) of the faculty development program. All Bridge Coaches attended 4 or more sessions, with roughly half attending all sessions and 35% attending 8 or 9 sessions. At the time of participation, all but one of the coaches were also working with residents as advisors, mentors, or supervisors.Feedback provided by faculty in the focus group and written survey responses indicated good acceptance of the faculty development program by participants. The majority of statements participants made about the program reflected a positive experience of the coaching training course  and considered its content and activities to be valuable . Participants greatly appreciated the monthly meetings with other Bridge Coaches and expressed wanting more opportunities to meet as a group to discuss challenges and share solutions between programs. Other suggestions for improvement included having more opportunities to repeat concepts and practice skills during and after the coaching training course, and adding more structure to scheduled meetings with coaches.Authentic Listening , followed by Asking Questions . Proportions for the domain Establishing Trust and Rapport were 61.1% and 58.3% for resident and peer ratings, respectively. Lastly, proportions for Coachee-focused Agenda were 45.4% and 58.3%, respectively.Participants’ performance on the formative GOSCE are presented in The online survey was completed by 15 (79%) Bridge Coaches. Prior to taking part in the faculty development program, 74% had no formal training in coaching and 68% had little to no experience providing or receiving coaching. Responses to the following question survey item are summarized in Coaching Skills, 3.(0.8) for Relational Skills, and 2.9(0.7) for Process and Structure. The skill with the greatest perceived change in all domains was establishing meaningful coaching relationships, which had a mean score of 3.58[0.66]. This was followed by facilitating coachee well-being and professional fulfillment (mean = 3.4[0.8]) and stimulating others to develop their own professional development learning objectives (mean = 3.3[0.8]), both in the Coaching Skills domain. The curriculum helped participants improve ‘a little’ to ‘somewhat’ in six skills. Least improvement was reported for meeting management (mean = 2.5[0.9]) and fostering the development of master adaptive learners (mean = 2.8[0.95]).Overall, participants reported improvement in coaching skills between ‘somewhat’ and ‘a lot.’ Mean participant scores for the three coaching domains were 3.1(0.6) for Adopting a coaching perspective represents a paradigm shiftEngaging in a coaching relationship with residents was a distinctly new experience for Bridge Coaches. Coaching required participants to use a different mindset, approach, and skillset than what they were accustomed to from their non-coaching faculty roles. They found that using coaching skills empowered their learners in a way that felt personally fulfilling. Participants recognized the powerful motivation that learners could derive from self-discovery.Layering coaching onto existing educational rolesThe participants held other positions as their coachees’ advisor/supervisor through their other educational roles. They noted challenges navigating two roles that were seemingly at odds with each other. However, participants appreciated having an insider perspective while coaching and felt they were able to utilize coaching in a potentially more interesting and engaging way for residents.Coaching faculty development and the community of practiceParticipants comments reflected that they viewed themselves as a community of practice. They were driven to work collaboratively to improve their coaching skills. Participants greatly valued the insight and perspectives of the other coaches.Seven (37%) GME Bridge Coaches participated in the focus group. Data from the focus group and responses to open-ended survey questions revealed three major themes related to participants’ experiences and perceptions of coaching:Subthemes and exemplar quotes from the focus group and survey responses are provided in As experienced mentors and advisors in medical education, the faculty that participated in our faculty development program already possessed many of the essential skills needed for coaching, such as the ability to build rapport with learners and support goal-setting practices. They required more practice with newer skills intended to facilitate the learner-driven approach of coaching – such as asking probing questions to guide learners toward self-discovery of solutions (rather than providing them) – and noted the novelty of taking on a coaching mindset as a GME educator. Insights provided by Bridge Coaches underscore the importance of having sufficient opportunities for practice and feedback to reinforce coaching skills, and the need for adequate structure to support a coaching curriculum in GME.This is a novel use of coaching to bridge the educational continuum from the end medical school and into residency. Given the unique structures of GME, having faculty embrace the coaching role while occupying other roles within the residents’ clinical learning environment is an important factor to consider to bring coaching experiences close to the authentic learning of residency. The TRA faculty development program was feasible and had good acceptance among participants. Faculty found that using coaching skills motivated and empowered their learners in a way that felt personally fulfilling to themselves. They expanded their professional identities to embrace their new roles as coaches, aligning with previously reported findings in the literature . By beinIt is not yet clear what structures for coaching enable optimal engagement with residents. There is an inherent tension between the structure needed in medical education and the learner self-directedness necessary for coaching. Unlike traditional dedicated coaching programs, faculty working in GME often have access to evaluation data, can work as direct supervisors, and may even be involved in promotion and remediation decisions . Thus, creating safe spaces for residents to be open, reflective, and vulnerable in coaching remains an area of attention. Positively, prior coaching studies have shown that GME learners may uniquely benefit from having coaches who are also authentic role models that possess a deep understanding of the complex learning needs of residents ,15. Intrhttps://navigator.iime.cloud/course/coaching/.In light of the positive feedback to coaching from the initial group of faculty coaches, as well as interest from other faculty to receive training, an asynchronous model of the training curriculum was created to expand faculty development in coaching throughout our institution. Using video lessons, independent readings, exercises, and small-group work, this curriculum provides a more flexible approach to training educators who are not able to dedicate time to a scheduled workshop series. This curriculum is available online at: The limitations of this project are its small scale and unique setting at an academic medical center where 30–40% of graduating medical students continue for residency each year. Data was collected to assess the experience of the program retrospectively, and not prospectively, which is a limitation of the design. Creating meaningful connections with learners prior to residency starting may be challenging in some settings. However, due to the limitations of the COVID-19 pandemic, the curriculum and coaching program took place in a largely virtual setting, which opened opportunities for expanding the reach of the curriculum. Increased comfort with virtual platforms facilitates the ongoing connection between coaches within the community of practice.Research is currently underway to better understand what trainees’ experiences are with the TRA coaching program, and how their interactions with GME Bridge Coaches inform their attitudes, well-being, goal-setting, and performance. Future research must examine how integrating coaching changes learner trajectories and performance. We aim to learn whether integrating coaching within the constraints of GME can influence the learning culture positively and cultivate the growth mindset and self-directed learning necessary for master adaptive learners.The promotion of learner agency, individual development, and resident well-being makes coaching well-suited to help ease the challenges of the UME to GME transition. Faculty were well-suited to serve as coaches for first-year residents, and felt fulfilled by their new roles. Continuous reinforcement of novel coaching skills and structures to support coaching encounters are necessary to facilitate coaching in GME.


A provincial program combining the effect of a government investment in prenatal screening and a specialized cardiac center was introduced in 2004, to improve prenatal diagnosis by echocardiography for congenital heart diseases (CHDs) in the Guangdong Registry of Congenital Heart Disease, China.To evaluate the effects of this program on the prenatal diagnosis rate (PDR) by echocardiography and termination of pregnancy (TOP).A retrospective study from 2004-2015 included 9782 fetuses and infants diagnosed with CHDs. The PDR was calculated for major and minor CHDs during pre-, mid- and post-program time-intervals. Multivariable logistic regression was utilized to analyze the associations between program implementation and the timing of CHD diagnosis  by different hospital levels. The rate for TOP were also evaluated.P for trend =0.041). A lower proportion of TOP were attributed to minor CHDs after the program.The PDR increased by 44% for major CHDs in the post-program interval relative to the pre-program interval. The three most frequently diagnosed subtypes prenatally were hypoplastic left heart syndrome (84%), double outlet right ventricle (83%) and severe pulmonary stenosis (82%). Participants with a high school education experienced a greater increase in PDR than those without a high school education. The odds for a prenatal vs. a postnatal diagnosis for major CHD were greater after introduction of the program than before . The TOP rate decreased from 52.3% pre-program to 19.6% post-program among minor CHD fetuses with a prenatal diagnosis (The program combining the advantages of government investment and a specialized cardiac center appeared to increase the PDR by echocardiography for CHDs in an unselected population. The TOP rate among minor cases with prenatal diagnosis declined significantly after implementation of the program. Congenital heart diseases (CHDs) remain the most common congenital malformations, with a global incidence of 6-12/1000 live births –5. PrenaGuangdong Cardiovascular Institute in Guangdong, China, initiated a program for improving the early diagnosis of CHDs with the support of the provincial government in 2004. Government policies promoted screening for congenital abnormalities, provincial networking, and professional training to improve detection, with the aim to improve CHD detection. Before 2006, sparse resources and few skilled ultrasonographers limited ultrasound screening for fetal abnormalities to evaluate obstetric complications or other high-risk pregnancies . HoweverIn this report, we primarily aimed to assess the impact of the GRCHD program on the prenatal detection rate (PDR) and timing of diagnosis for CHDs, in an unselected population. We also examined the influence of the program on the termination of pregnancy (TOP) in the GRCHD.The provincial improving program included three major components and was summarized into “4P” Mode :The specialized cardiac center, Guangdong Cardiovascular Institute, established and maintained a network of GRCHD across the province with the support of the Guangdong Department of Health, since 2004, aiming to unify the diagnosis and treatment of CHD. The network included the largest local hospitals and maternal and child care centers from various geographic areas across Guangdong province. Beginning with 19 surveillance sites at inception, the network gradually expanded to 39 sites in 20 cities at present, including primary, secondary, and tertiary hospitals , 11. TheGuangdong Cardiovascular Institute offers annual technical and standardization training on CHDs for staff from all network sites, including echocardiography knowledge and skills, fetal and infant cardiac anatomy, prenatal counseling, clinical management of CHDs, and intervention strategies. Completion of a 3-month intensive pediatric echocardiography in-service training program, offered by Guangdong Cardiovascular Institute, is required for the key echocardiographer from each network site. Guangdong Cardiovascular Institute also offers on-site and off-site technical consultation to network sites, provides timely feedback on referral cases, and helps improve diagnostic skills at lower-level facilities.use of in vitro fertilization, in accordance with the practice guidelines for the performance of fetal echocardiography . Patient consent were obtained.All CHDs in newborns and stillbirths are reported to the national registry system for all birth defect. More detailed information obtained from hospital medical records is provided to the GRCHD. The GRCHD also obtains information from mothers through face-to-face interviews and a structured, standardized questionnaire on CHD risk factors as previously reported .All CHD cases in the GRCHD were coded by two clinical epidemiologists, with more than 20 years of experience in pediatric and adult cardiology, based on the International Classification of Diseases, 10th Revision (ICD-10) (Q20.000-Q28.000). CHD was classified into major CHDs and minor CHDs based on previous reports with slight modification . Major CP for trend was calculated by Cochran-Armitage trend test to estimate changing PDR trends during the different program time intervals. Multivariable logistic regression models were used to estimate the odds of a prenatal vs. postnatal diagnosis for major CHDs in the pre-program and mid-program/post-program intervals, stratified by different hospital levels. Factors adjusted in the multivariable regression was those highly related to the prenatal detection of CHDs, such as maternal age (>35 / ≤ 35 years), domestic migrant population , maternal education (more than high school/completion of high school/less than high school), total previous live births (0/1/≥2), family history of CHD (yes/no), maternal diabetes , multiple gestation (yes/no), infant sex , extra-cardiac defects or chromosomal abnormality (yes/no), and fetus with suspected cardiac abnormality on basic obstetric ultrasound (yes/no). The multiplicative scale of interaction was calculated by evaluating the product term for time-intervals or other factors and hospital levels. The statistical significance of the product term was determined by using the Wald statistic.The 12-year period was divided into three time-intervals, 1) 2004-2005, was defined as the “pre-program” interval, as there were no provincial CHD diagnosis data available before 2004; 2) 2006-2010, was defined as the “mid-program” interval; and 3) 2011-2015, was defined as the “post-program” interval. Characteristics of the participants, PDR, and timing of diagnosis were described for each CHD subtype by different intervals. The PDR was calculated as number of prenatal diagnosis cases divided by the total cases, for different CHD group , CHD subtypes, and different program time intervals. n = 486), domestic migration status (n = 112), maternal education (n = 46) or maternal previous live births (n = 43) were not imputed during analysis. Data were analyzed using SAS . Statistical tests were two sided with a significance level of P < 0.05.Missing data for maternal age (P < 0.05). During the study period, an increasing number of diagnoses were made at secondary compared to tertiary hospitals. The proportion of CHD cases diagnosed by tertiary hospitals significantly decreased (P for trend <0.001) from 70% pre-program to 46% post-program, while the proportion of CHD cases diagnosed by secondary hospitals significantly increased (P for trend <0.001), from 29% pre-program to 51% post-program.A total of 9782 cases were diagnosed with CHD, among 1046456 fetuses and infants during the study period . CompareP for trend <0.001). The major CHD PDR increased 44 percentage points  an average increase of 4 percentage points per year. The minor CHD PDR increased 9 percentage points from pre-program (4%) to post-program (13%) (P for trend <0.001).Of 9782 CHD cases diagnosed from 2004-2016, 2184 (22%) were diagnosed prenatally. Of note, the PDRs for total CHDs and CHD subgroups increased over time . OverallExcept for severe PS, all CHD subtypes experience dramatic increases in the PDRs . The mosP for trend <0.001). Postnatal CHD diagnosis also advanced significantly , with most major post-program CHDs detected within three  to seven days  after delivery.The times of prenatal and postnatal diagnosis also greatly advanced as shown in use of in vitro fertilization, and so on. Except for the major CHDs, total CHDs and minor CHDs with these indicators were more easily to be detected prenatally , while the TOP rate dropped from 52.3% to 19.6% among minor CHD fetuses with prenatal diagnosis (P for trend = 0.041). The TOP attributed largely to major CHDs, progressively lower proportion of TOP were due to minor CHDs after the program  increased from 35.8% in 2002 to 59.7% in 2012 after the 2007 introduction of a national prenatal screening program  . And notWe also found that the overall and minor TOP rate for CHDs with prenatal detection in the current study was lower than our previously report about the specialized prenatal consultation service in our specialized center  . The disThis study is one of the few and the largest studies to report a provincial program to improve the PDR across the region. The long study period enabled assessment of the program by different time intervals, and the large number of cases size enabled evaluation of PDR by different CHD subtypes. Also, we evaluated the change for TOP rate by program progress. In addition, each CHD case was individually reviewed by two clinical epidemiologists trained in pediatric and adult cardiology. Similar to several previous studies , 26, ourHowever, there were several potential limitations of the study. First, the GRCHD is not a province-wide registry, only covering about 12% newborns from the whole province. Therefore, it could not capture all CHD cases from the province. However, the GRCHD included the largest local hospitals and maternal and child care centers from each city across Guangdong province, which have the capability of detecting CHD prenatally or in newborns. We think the GRCHD could represent the overall level for diagnosing CHD across the whole province. Moreover, there was no control group without any program implementation, or a parallel data set for comparison. An ongoing project using two parallel population-based cohorts with and without program implementation, is conducted in Zhongshan City, Guangdong Province, which is expected to shorten this limitation. Several other factors may contribute to improved PDR, including affordability, social insurance schemes, and access to healthcare in general. It was a limitation that we did collect these data to evaluate their influence. Furthermore, the influence of differences in diagnosis time on later mortality, morbidity, and quality of life of the affected babies is not currently available. The long-term follow-up for these CHD patients and prognosis evaluation is required, to validate the effect of prenatal diagnosis.The results of this large multicenter study indicate that a program combining the advantage of government investment, and a specialized cardiac center is an effective means to improve the PDR of CHDs in an unselected population. The TOP rate among minor cases with prenatal diagnosis declined significantly with the program. We presume that similar programs will be effective for improving prenatal CHD diagnoses in other large Chinese provinces and in Asian countries with different levels of hospitals. Future studies will be necessary to evaluate the effectiveness of this approach in different populations.ouyanqiu@gdph.org.cn.The datasets presented in this article are not readily available, because the data was generated from different hospitals of the GDCHD network. We were not authorized to share the data outside the network. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by the Ethics Committee of Guangdong Provincial People's Hospital (Reference number: GDREC2011135H). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.YO and JC conceived and designed the study and designed the protocol. YO, JM, and MF conducted the statistical analysis. MB critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the National Key Research and Development Program [No. 2018YFC1002600], the National Natural Science Foundation of China [No. 81903287], the Natural Science Foundation of Guangdong Province [Nos. 2021A1515011445 and 2020A1515010743], Guangdong Provincial Key Laboratory of South China Structural Heart Disease [No. 2012A061400008] and Guangdong Provincial Clinical Research Center for Cardiovascular Disease [No. 2020B1111170011].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Extracorporeal membrane oxygenation (ECMO) for temporary cardiopulmonarysupport is one of the most intense and technologically complex therapiesoffered in medicine. It is a high-risk procedure that requires specificknowledge and technical skills to perform it with good results.The main goal of this study is to describe our extracorporeal membraneoxygenation (ECMO) training program based on the study of specialized nursesand physicians of a simulation teaching experience, conducted in a pediatriccardiac intensive care unit. The program was developed as atheoretical-practical course with final exam and annual maintenance trainingsessions, caring for ECMO patients, its implementation and results.A descriptive study for registered nurses, intensivists, and cardiacsurgeons. A self-administered, anonymous, and voluntary survey was conductedto assess the long-term perception about the program. Demographic data todescribe the population was required, and questions about satisfaction andconfidence in acquired skills and competences were asked. A descriptivestatistical analysis was performed; patient survival and complications werecompared before and after ECMO program using chi-square test, and P<0.05was considered statistically significant.Twenty-four training courses were performed for 68 professionals. More than88% of the professionals considered the course components to be adequate andcomplete; and 94% felt trained to manage the ECMO circuit. Most valuedactivities were workshops and clinical cases. Since the implementation ofthe training program, 88 patients were assisted, with a survival rate atdischarge of 58%, higher than in the previous period (P=0.03).More than 80% of the professionals considered the workshops and simulationsas the most useful components. Reliance on the circuit care was higher thanin training problem scenarios. Since 2013 we assisted 88 patients on ECMO,with a survival rate at discharge of 58%, within international standardsresults. It is a high-riskprocedure that requires specific knowledge and technical skills to perform it withgood results. At our hospital, 600 patients per year undergo congenital heartsurgery with a mortality rate of >5%. We developed our ECMO program in 2006 and, together withsurgeons, perfusionists, nurses and cardiac intensivists, cared for 123 ECMOpatients with a 54% survival rate at discharge. In 2012, facing the lack of perfusionists, we were forcedto develop a different mode of care, in which control and monitoring of ECMO circuitis performed by trained nurses and physicians supported by specialist nurses on-callwho provide support on a 24/7 basis. Each patient is cared for 24 hours a day by twoprofessionals, one of them for the circuit, pump control and monitoring, and theother for specific nursing care. To implement this mode of care, we developedprotocols for ECMO patient care and a training program following the ExtracorporealLife Support Organization (ELSO) guidelines. We considered that simulation-based training would be anappropriated teaching tool to acquire the necessary competences to bring qualifiedcare for these patients.Extracorporeal membrane oxygenation (ECMO) for temporary cardiopulmonary support isone of the most intense and technologically complex therapies offered in medicine.Nowadays, it is considered a standard of treatment in congenital heart defectsrepair and 1-2% of the patients are supported with it during postoperativecareThe objective of this study is to describe the training program and itsimplementation, to analyze the teaching performance from the perspective of theparticipants, and to review clinical outcomes with the new mode of care after 8years of its implementation.Design: Descriptive study about a simulation teaching experience.Setting: Pediatric cardiac intensive care unit.The training program began in 2013 and was addressed to pediatric cardiacintensive care unit (PCICU) physicians and nurses. We developed atheoretical-practical course with a final exam, and periodical maintenancetraining sessions. In-person and online lessons, readings and videos wereavailable in our virtual campus, followed by workshops to address ECMO circuitoperation, and simulation of emergency scenarios performed in our SimulationCenter. Participant requirements were to be a pediatric intensive carecertificated physician, pediatric critical care registered nurse, orperfusionist with more than two years’ experience in our unit. Minor changeswere made along the years without affecting the basic structure of the trainingmodel organized into basic course, advanced course, and periodic trainingsessions to maintain skills. The most relevant chapters of the ELSO trainingmanual were translated for better understanding and used as mandatorybibliography.To complete the training course, professionals were required to pass a finaltheoretical multiple-choice exam and a practical exam of acquired skills in twosimulation scenarios developed with the team. A detailed curriculum of theprogram is outlined in Once approved, the professionals of the course joined the ECMO team, withincreasing responsibilities in patient connection and disconnection, circuitmonitoring, replacement, and patient transport. Members of the ECMO team mustrepeat the advanced course annually and take care for at least two ECMO patientsper year  .To evaluate the long-term perception of the training program, aself-administered, anonymous, and voluntary survey was conducted to all nursesand physicians of the PCICU (RedCap) after 8 years of continuing educationactivities. A small set of demographic data to describe the population wasrequired, and questions addressed to evaluate satisfaction and confidence inacquired skills and competences throughout the program were asked. Theeducational resources evaluated in a 4-point Likert scale included: didacticmaterial, theoretical classes, workshops, clinical cases, and simulationsessions. A reminder after two weeks to maximize the response rate was emailed.The survey is outlined in This study was approved by the Institutional Review Board (IRB) of our hospital,who waived the need for informed consent (protocol investigation No. 1272).P<0.05 assignificant.To assess the impact of the program in patient outcomes, we compared ECMO patientsurvival in two periods: 2006-2012 and 2013-2020. Descriptive and statisticalanalyses were performed; results are expressed as absolute values andpercentages or median and interquartile range (IQR) as appropriated. Resultswere compared by chi-square tests, considering a st interactivesymposium with simulation scenarios for specific issues, workshops on surgicalmanagement and specific nursing care for children on ECMO.Overall, we performed 24 courses (9 basic and 15 advanced), and different activitiesrelated to maintenance training. Seminars with specialists from other centers,technology updating workshops, and organization of the 1Sixty-eight professionals attended the courses: 32 intensivists and 36 critical careregistered nurses, all of them with more than 2 years of experience in the PCICU.Sixty percent of them (41) are still participating in the ECMO maintenance trainingprogram.Regarding the survey results, 68% of the responses (70/102) were received.Eighty-eight percent of the respondents attended to ECMO training activities fromthe beginning of the program, and currently 50% of them are members of the ECMOteam.Seventy percent of the nurses (35/70) cared for ECMO patients between 2012-2020; 57%took care of more than 10 patients/circuits, 37% between 5 and 10 patients, and only6% less than 5 patients. More than 88% considered the campus teaching resources,theoretical lessons, and simulation sessions adequate and complete; 94% considereduseful in patient care. More than 50% felt well trained in managing ECMO circuit,although some differences according to the scenario were observed . General.Twenty-two percent of the patients were neonates, and 11% of the entire populationhad single-ventricle physiology. Complications were extremely frequent; 72% of thepatients had at least one, bleeding in first place (56.9%), and 46% required renalreplacement therapy.Since 2006, when the program was launched, 123 patients were assisted with ECMO, fora median time of 3 days (IQR 1-12), median length of stay of 20 days (IQR 1-34) with54% survival at dischargeP=0.5), and survival at discharge wasslightly higher in 2013-2020 (P=0.03), We found no significant differences between the two periods. Proportion of neonateswas similar in both periods  where ELSO recommends complementarycontinuing medical education to all team members. As other published works, simulation scenarios (80%) andpriming and troubleshooting workshops were, in our group, the activities consideredas essential in maintaining skills-16.Considering the evidence about traditional education by learning models that failswhen cases are not very frequent or there is a global lack of team experience as inour case, we decided to develop a training program following institutionalguidelinesThe implementation of the simulation-based training program would provide our ECMOteam, especially nurses, with the necessary competences to provide continuous careto these critical patients. This training used multiple learning formats, includingbasic courses with high theoretical content, workshops with traditional simulationand deliberate practice, resolution of high-fidelity health care simulationscenarios with high realism and discussions based on reflection about thepractice. demonstrated intheir study about prospective assessment in novices that all participants describeddidactic education and simulation scenarios as useful to improve their perception ongeneral knowledge, capacity to accomplish critical criteria required in simulatedemergencies, and general confidence. Similarly, analyzing our team perception, itwas found that more than 80% considered the training highly useful, but we noticed adifference in the perception of it to the different scenarios proposed. This leadsus to think about the need to reinforce the features and frequencies of trainingencounters. A combination of these formats seems to be a proper structure andwell-received by the participants. Balancing active repetition with the inherentcognitive load, especially in leadership roles and in those sessions mainlycognitive based, allows for stress reduction and the incorporation of physiologicalconcepts that, finally, must be applied at the patient's bedside. With our program,training not only improved the immediate performance. The follow-up of participantsshowed the continuous incorporation of the concepts learned and trained during thetraining to the patient’s real experience. This is proven by survival results andsimilar complications during the initial implementation in the first years withcertified perfusionists.Chan et al..Lastly, it is important to note that the continuity of the training program is basedon ECMO team participants who organize the training of the new ones and overseeperiodical training of its members. It is important to mention that outcomes showedno significant differences between the two periods, the first exclusively withperfusionists and the last with specialist nurses caring for the patients. Theimprovement in survival in the last years is probably due to the increasingexperience of the whole team in this procedure. As the main goal of this paper wasto present our training program, we did not focus on detailed outcomes that werepublished in a previous reportIn the frame of simulation-based ECMO training program, 24 courses and severalcontinuing teaching activities were carried out over a period of 8 years.Sixty-eight professionals from the PCICU were trained, of which 60% are still partof ECMO team. More than 80% considered the training program as positive, consideringworkshops and simulation as the most useful components of the program.Professional's confidence in the care of the circuit was greater than in othersituations. Since 2013, the program allowed us to provide ECMO to 88 patients with a58% survival rate at discharge, results within international standards.