Training and Recruitment Strategies for Developing Sustainable, Global, Research Workforces in Low-Resource Settings: Perspectives From The International Family Study

: 1.016_HHR Challenges Faced by a Pre-vocational and Vocational Training Center for Adults with Autism-Spectrum Disorders (ASD) and Intellectual Disabilities (ID) in a Town in Northern India N. Bhullar, N. Bhullar; APAAR, Morton, PA, USA, IIMB, Bangalore, India Background: There is limited knowledge about adults with ASD in India and even less is known about their pre-vocational and vocational rehabilitation with a few exceptions (e.g. Daley, Weisner, & Singhal, 2014). This study examines the challenges faced in a center set up in one medium-sized town in North India with the aim of providing rehabilitation to this population during the course of three years. Methods: Qualitative study. Findings: These challenges included diagnosis of ASD and other IDs, parental motivation, transport, staffing recruitment and retention, behavioral challenges and lack of professional guidance, and societal awareness. One of the first major challenges faced by the center was the lack of definitive diagnosis of individuals with ASD. As there were no psychiatrists who diagnose ASD in town, parents were directed to another major city about three hours away. Several parents lacked motivation to alter their children’s routine and were more likely to prefer the status quo. Almost all of the adults with ASD and IDs had been primarily staying at home for several years and did not have a social life or major interaction with people outside their homes. Some parents did not seem eager to alter their lifestyles to accommodate their children’s need for rehabilitation. Problems in transportation cropped up with limited public transport options available in the town. Staff recruitment and retention was a challenge with relatively few educational institutions catering to special education, as well as fewer graduates, who have to grapple with salaries lower than the average entry-level positions. Behavioral challenges in trainees at the center included self-injurious behavior, aggressive behavior towards their trainers, soiling themselves, and inability to change their repetitive and disruptive behavior. Professional guidance to manage these behavioral challenges was difficult to obtain consistently. Interpretation: A lot of the above-mentioned challenges are directly or indirectly influenced by lack of societal awareness for these disorders in this cultural context. For instance, van drivers hired for transportation of trainees have been erratic in their attendance and punctuality, not realizing the need for a more fixed routine for the trainees and the havoc it may cause in the latter’s training. Solutions are proposed which include collaboration with local health systems. Source of Funding: None. Abstract #: 1.017_HHR: 1.017_HHR Training and Recruitment Strategies for Developing Sustainable, Global, Research Workforces in Low-Resource Settings: Perspectives From The International Family Study F. Brindopke, S. Ly, A. Auslander, P. Sanchez-Lara, K. Magee, W. Magee; Children’s Hospital Los Angeles, Los Angeles, CA, USA, University of California, Los Angeles, USA, Children’s Hospital Los Angeles, Los Angeles, California, USA, Children’s Hospital Los Angeles, Los Angeles, USA, Operation Smile, Inc., VA Beach, VA, USA Program/Project Purpose: As our world has undergone globalization, individuals, institutions, and organizations now have the ability to launch campaigns, research projects, and interventions throughout the world. Thus while this has presented tremendous opportunities in global health, it also raises challenges of how workforces will be recruited to achieve these goals. With our global research collaboration, The International Family Study, we have been able to recruit and train global teams to carry out essential research functions and achieve continual project growth. Structure/Method/Design: The starting point for building local teams and workforces begins with the recruitment process. We have primarily used a partnership approach where institutions and other organizations are used as hubs to find the ideal people to get involved. Different workforce models have also been used successfully throughout implementation of the project, which include volunteer, contract-based, and mixed-funding. Models are chosen based on resources, educational experience and geographical settings. For training methods, the ‘train the trainer’ approach has been heavily utilized, allowing for growth and sustainability within local groups. Evaluation after training is also critical for project success and conducted through personalized quality control reviews. Outcome & Evaluation: Through our various methods of team building, we have recruited a global workforce to carry out essential research functions. With over 100 individuals trained (75% of which represent unpaid volunteers) throughout the world it has allowed our project great flexibility to gather large-scale amounts of data. In evaluating recruitment, partnership pipelines with other volunteer Health Systems and Human Resources A n n a l s o f G l o b a l H e a l t h , V O L . 8 3 , N O . 1 , 2 0 1 7 J a n u a r y eF e b r u a r y 2 0 1 7 : 1 8 – 5 8 26 organizations or educational institutions have been the most successful grounds for growing workforces. Going Forward: These experiences aim to help global research and intervention programs create teams for large-scale global projects. Training and recruitment go hand-in-hand and must be concurrently achieved for success. The importance of retaining involvement from those individuals who are recruited and invested in by training is critical, particularly with higher-level tasks. In addition, volunteerbased models must also consider the personal interests and motivations of their individuals and determine how to best incentivize retention. Each setting offers new challenges, but by recruiting and training sustainable local workforces, projects ensure they will have local teams leading the charge in their global health efforts. Source of Funding: Operation Smile International Margeurite Foundation Sorenson Foundation. Abstract #: 1.018_HHR: 1.018_HHR Long-term Patient Follow-up for Short-term Surgical Trips Is

The effectiveness of CBHWs was assessed by conducting Key Informant Interviews (KII) with Medical Officers and four Focus Group Discussions (FGDs) with patients utilising these services.
Findings: The four CBHWs were actively involved in organising weekly psychiatry clinics. Thus far about 1600 patients from 206 villages have utilised this clinic. In the year 2015 alone, a total of 52 clinics were conducted accomplishing 1013 consultations. The CBHWs have made 556 village visits with 3795 patient and family contacts and travelled a distance of 6921kms.
The KIIs with doctors revealed that the CBHWs are a valuable resource for the centre's multitude of services. The FGDs with patients revealed that home visits by health workers have resulted in changing the attitude of their care givers and family members towards their problem, clearing of misconceptions and reduced stigma.
Interpretation: Continued recruitment of new patients, regular follow-up visits, data collection skills indicates the effectiveness of CBHWs in delivering primary mental health care services. CBHWs are acceptable to the community and health functionaries. CBHW have played a vital role in this service and the same model can be used in lower and lower middle income countries in improving the mental health of a rural community.
Source of Funding: The rural mental health programme "Maanasi" is funded by Rotary Clubs of Midtown, Bengaluru, India and Howard West, USA.
Abstract #: 1.016_HHR Challenges Faced by a Pre-vocational and Vocational Training Center for Adults with Autism-Spectrum Disorders (ASD) and Intellectual Disabilities (ID) in a Town in Northern India N. Bhullar 1 , N. Bhullar 2 ; 1 APAAR, Morton, PA, USA, 2 IIMB, Bangalore, India Background: There is limited knowledge about adults with ASD in India and even less is known about their pre-vocational and vocational rehabilitation with a few exceptions (e.g. Daley, Weisner, & Singhal, 2014). This study examines the challenges faced in a center set up in one medium-sized town in North India with the aim of providing rehabilitation to this population during the course of three years.
Findings: These challenges included diagnosis of ASD and other IDs, parental motivation, transport, staffing recruitment and retention, behavioral challenges and lack of professional guidance, and societal awareness. One of the first major challenges faced by the center was the lack of definitive diagnosis of individuals with ASD. As there were no psychiatrists who diagnose ASD in town, parents were directed to another major city about three hours away. Several parents lacked motivation to alter their children's routine and were more likely to prefer the status quo. Almost all of the adults with ASD and IDs had been primarily staying at home for several years and did not have a social life or major interaction with people outside their homes. Some parents did not seem eager to alter their lifestyles to accommodate their children's need for rehabilitation. Problems in transportation cropped up with limited public transport options available in the town. Staff recruitment and retention was a challenge with relatively few educational institutions catering to special education, as well as fewer graduates, who have to grapple with salaries lower than the average entry-level positions. Behavioral challenges in trainees at the center included self-injurious behavior, aggressive behavior towards their trainers, soiling themselves, and inability to change their repetitive and disruptive behavior. Professional guidance to manage these behavioral challenges was difficult to obtain consistently.
Interpretation: A lot of the above-mentioned challenges are directly or indirectly influenced by lack of societal awareness for these disorders in this cultural context. For instance, van drivers hired for transportation of trainees have been erratic in their attendance and punctuality, not realizing the need for a more fixed routine for the trainees and the havoc it may cause in the latter's training.
Solutions are proposed which include collaboration with local health systems.
Source of Funding: None. Program/Project Purpose: As our world has undergone globalization, individuals, institutions, and organizations now have the ability to launch campaigns, research projects, and interventions throughout the world. Thus while this has presented tremendous opportunities in global health, it also raises challenges of how workforces will be recruited to achieve these goals. With our global research collaboration, The International Family Study, we have been able to recruit and train global teams to carry out essential research functions and achieve continual project growth.
Structure/Method/Design: The starting point for building local teams and workforces begins with the recruitment process. We have primarily used a partnership approach where institutions and other organizations are used as hubs to find the ideal people to get involved. Different workforce models have also been used successfully throughout implementation of the project, which include volunteer, contract-based, and mixed-funding. Models are chosen based on resources, educational experience and geographical settings. For training methods, the 'train the trainer' approach has been heavily utilized, allowing for growth and sustainability within local groups. Evaluation after training is also critical for project success and conducted through personalized quality control reviews.
Outcome & Evaluation: Through our various methods of team building, we have recruited a global workforce to carry out essential research functions. With over 100 individuals trained (75% of which represent unpaid volunteers) throughout the world it has allowed our project great flexibility to gather large-scale amounts of data. In evaluating recruitment, partnership pipelines with other volunteer Health Systems and Human Resources J a n u a r y eF e b r u a r y 2 0 1 7 : 1 8 -5 8 organizations or educational institutions have been the most successful grounds for growing workforces.
Going Forward: These experiences aim to help global research and intervention programs create teams for large-scale global projects. Training and recruitment go hand-in-hand and must be concurrently achieved for success. The importance of retaining involvement from those individuals who are recruited and invested in by training is critical, particularly with higher-level tasks. In addition, volunteerbased models must also consider the personal interests and motivations of their individuals and determine how to best incentivize retention. Each setting offers new challenges, but by recruiting and training sustainable local workforces, projects ensure they will have local teams leading the charge in their global health efforts.

Source of Funding: Operation Smile International Margeurite Foundation Sorenson Foundation.
Abstract #: 1.018_HHR

Long-term Patient Follow-up for Short-term Surgical Trips Is Possible
J. Broecker 1 , J. Rappaport 2 , C. Poorman 2 , W. Liu 3 , M. Lagina 2 , L. Philipp 2 , J. Srinivasan 2 , J. Sharma 2 ; 1 Emory University School of Medicine, Atlanta, GA, USA, 2 Emory University School of Medicine, Atlanta, USA, 3 Emory University School of Medicine, Atlanta, Georgia, USA Background: Achieving adequate follow-up for surgical patients is challenging in resource-poor environments, especially for short-term surgical trips. The aim of this study was to evaluate the extent of follow-up using mobile phones to reach patients post-operatively and to evaluate post-surgical quality of life.
Methods: At a single institution, the School of Medicine and Department of Surgery have provided surgical care yearly to patients at a public hospital in the central plateau of Haiti since 2008. During the 2016 surgical trip, 2014-2015 surgical patients were called on mobile phones to invite to clinic for follow-up evaluation. Patients who were unable to return to clinic were interviewed over the phone. Quality of life was determined using an institution-generated tool that measured patients' ability to perform activities of daily living (ADLs). For prostatectomy patients, the tool also incorporated the International-Prostate Symptom Score (I-PSS) tool.
Findings: With a mean length of follow-up of 17.8 months (range: 3-60), follow-up was achieved in 34 (28%) of 122 operative patients. 19 (56%) of these patients returned to clinic, 25 (74%) were able to be reached by phone, and 2 (6%) were reached via another source. Prior to using mobile phones to facilitate follow-up, four operative patients returned to clinic during the two previous trips. Followup patients had received the following operations: 14 inguinal hernia repair, 8 open prostatectomy, 5 lipoma removal, 2 hydrocelectomy, 1 cystoscopy and dilation, 1 celiotomy for bilateral kidney stone obstruction, 1 meatoplasty, and 1 drainage for enlarged cervical lymph nodes. Mean age was 44 (range: 6-76). Mean travel time for patients was 65 minutes (range: 5-300). At follow-up, there was a 41% improvement in patients' ability to perform ADLs and a 38% reduction in reported pain from the pre-operative period.
Interpretation: Achieving long-term follow-up for operative patients following short-term surgical trips is challenging but mobile phones facilitate follow-up. Barriers encountered that limited the extent of follow-up included language barriers, limited means of communication with patients, far travel distance for patients, and limited time in country. The follow-up data obtained demonstrates that quality of life appears to improve after short-term surgical trips.

Comprehension of Surgical Informed Consent in Haiti
J. Broecker 1 , C. Sutton 2 , L. Demma 3 , G. Lynde 3 ; 1 Emory University School of Medicine, Atlanta, GA, USA, 2 Texas Children's Hospital, Houston, USA, 3 Emory University School of Medicine, Atlanta, USA Background: Informed consent has long been considered an essential requirement of surgical care in the United States; however, US studies have demonstrated that patient comprehension of informed consent is poor. Little is known about the use of informed consent on international surgical trips.
Methods: Since 2008, a multi-disciplinary team from a single institution has partnered with a public hospital in the central plateu of Haiti to provide surgical care on an annual trip. Written and video informed consent tools were developed that explained the procedures, risks and benefits of both surgery and anesthesia and were translated into Creole. All 2015 surgical patients (n¼52) received the dual-media informed consent prior to surgery. Procedures performed were primarily inguinal herniorraphy(50%) and open prostatectomy(17%). Following the informed consent, with assistance from hired translators, patients completed a multiplechoice survey translated into Creole evaluating their understanding of and satisfaction with the procedures using an iPad survey app both before(n¼48) and after surgery(n¼47).
Findings: Following informed consent, 91% of patients were able to correctly identify their surgical procedure. The majority of patients were able to identify the most common risks of surgery including pain (85%), bleeding (80%) and infection (70%). Hernia patients struggled to identify the more complex possible complications such as recurrent hernia (31%) and chronic testicular pain (23%). In contrast, patients believed impotence (17%) and death (33%) to be likely complications. The majority (89%) of patients claimed they understood the video, but 30% had additional questions. The majority (61%) noted difficulty communicating through hired translators and only 35% were able to complete the surveys independently either due to inability to read (54%), difficulty understanding the questions (28%) or difficulty using the iPad itself (33%). Almost all (98%) patients were satisfied with the informed consent process and 91% of patients would have their operation again at discharge.
Interpretation: The results of our survey demonstrate that a multimedia informed consent tool can prepare patients for surgery but that communication barriers such as language and literacy inherent to the setting of international surgical trips should be considered in