Know Before You Go

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Know Before You Go

The first HBS program was introduced in 2010, and over the past decade the global community of HBS trainers has learned a lot about teaching these lifesaving curricula around the world. In our ongoing commitment to develop resources to advance quality newborn health in limited-resource settings, we asked trainers to share their experiences with us. Whether you are an experienced HBS trainer or planning your first training, here are a few questions—and answers—to know before you go.

If you have additional insight and experiences to add, please consider submitting via the form below.

What is one thing you would have done differently if you were able to?

I wish I had brought interpreters with us; spent more time in a local community prior to teaching the courses, and buy more bag/masks (our learners all needed one!).

I wish I had allowed for more time! More time for follow-up up/refresher courses. More time doing the course over two days. More time for practice!

I would always try to make the training more engaging and get the participants more involved. This is not something I did consistently when I first started training but then saw how important leading warm ups, songs and games were to participants. Involving them in leading activities was so helpful and I always incorporate this now.

I wish I had done better pre-assessments and had brough more equipment.

I wish I had provided training materials well in advance for learners to review ahead of the training.

I wish I had slowed down and practiced more.

I should have started with training physicians instead of midwives. We were told training had been done with physicians but did not happen as much as we originally believed.

I should have shared enough printed color posters (1 for each student), and asked more questions about our audience to be prepared to meet their training needs.

I wish I had developed local contacts better. Getting contact info of several physicians/midwives is important in continue to support the local facilities.

Demand for the training was high. Many who attended the training did not attend deliveries on a regular basis. Even though it may be difficult, I would limit participation to only providers frequently attending deliveries.

I wish I had provided enough equipment that they each had their own manikin.

Had more frequent courses with fewer participants on each.

I always take cloth baby blankets with me and leave them with the midwives or host. The paper ones in the kits do not hold up well with repeated use. My first trip the paper blankets were pretty ugly by the time we left. ECEB is a great course but parts of it do not work in certain countries or communities. On one trip, where we planned HBB for day one and ECEB for day two, we found that the providers could not all return on day two. By the end of that trip we were teaching HBB and the appropriate parts of ECEB in the same day. I always bring dog toy squeakers or squeaky children's toys (dollar stores are great for these) as the squeakers to make the baby 'cry' break easily. I would be firmer about what we can and cannot do. I always try but it is hard when doing things over the internet or phone from thousands of miles away and working with a country that has so many needs. I would always bring something to give away to the students. I wish HBS had something we could purchase at a reasonable price with the HBS logo. Flashlight, scissors, usb charger, water bottles. I know there are pins - we should advertise that more. When I went to Ghana the students wanted gifts and I did not have any. I felt so bad.

Have more assistant trainers.

Have HBS have an evidence-based educational platform for facilitators and include it into the curriculum.

Had more neonatalie kits

All of the above. Some we did well, e.g. connecting with the health authority, but we did not identify local champions.

What advice would you offer others implementing and/or sustaining HBS programs in the field?

Know the program well and practice a lot before you train others! I practiced with high school students who stopped me when I was being unclear. They knew immediately when I wasn't confident or following the program because they weren't trained medical professionals. Just saying it aloud and seeing how they reacted to the various program components helped me identify areas where I could improve teaching. This is a great way to simulate an audience with lower levels of clinical education than you might originally expect to find.

Be very clear on your needs for both equipment and space. Be very clear on what you can - and cannot do. You cannot have 12 students to one instructor. You cannot skimp on equipment. And be prepared for everything to change. Plan for people to be late to class. Plan your start time early as students may not get there on time. Find out ahead of time regarding safety for people when traveling - you may have to start early so that you can end before dusk so that women can safely get home. Dialogue with the host prior to arriving so that you can ascertain the safety issues, bus schedules, etc.

Do an assessment before you go to teach. Work on developing a strong in-country partnership in order to create a sustainable program.

Know your audience. I always want to know what resources they do or do not have so that I teach according to the resources they do have. Understand they will not be able to perform as if they work in a US hospital. It will be different, but they have the talent and desire to do a good job for their patients. Help them figure out the work-arounds. Give them the gift of confidence that comes with knowledge. Return again and again to continue to mentor. Let them contact you with questions and stories of successes. Help them set up quality improvement (QI) systems and check to be sure they are continuing to use the systems. Check in with their QI teams and hold them accountable—and be supportive.

Plan both the education and the sustaining phase, and determine the team who will impact the ultimate success. This will almost always include the health authority and hospital leadership. Identify local champions, and plan further remote support of these individuals. Create a "community" of learners.

Plan, plan, plan, and then plan some more! Anticipating every possible struggle or complication is what helped my team survive. Having team members with critical thinking skills is a MUST.

Go for it! Engage your students by telling stories of your experiences and encouraging them to tell stories of theirs. Use our imagination and praise a lot! To summarize what was learned, we used a ball of yarn—and standing in a circle, we asked each learner to say one thing they learned or that they would do differently. Each person then tossed the ball to another after sharing. At the end, the string formed a "spider web" and we put the manikin on it to show how we could now "support" the baby with our new knowledge. Also, make the training fun and enjoyable—make them laugh. For example, I teach the rhythm of bagging by singing and dancing a waltz. I might look silly, but the students laugh and will never forget it!

Prepare yourself! Allow yourself enough time to go through the material slowly. Then allow ample time during the training. Some participants may not have any prior experience, or English is their second (or third!) language. Speaking slowly and clearly is important, and you may need to use an interpreter. Plan this before you go!

Always prepare yourself by reviewing the materials! Collaborate with individuals from different perinatal fields (or even nonclinical friends/family).
At the training, ask participants:
a. What will you remember about HBB?
b. What will you no longer do (when caring for babies after birth)?
c. What practices will you incorporate into your care at birth?
Also important:
Identify strategies with in-country partners for sustainability.

Be aware and empathetic of local barriers and challenges.

Train and re-train and leave a NeoNatalie where healthcare providers can get frequent practice between deliveries etc.

Make sure there are systems in place for on-going support and communication. Return to do more trainings and testing. Create benchmarks for institutions to determine when they've integrated the skills into their protocols effectively. We saw a dramatic reduction in newborn death, but it took approximately two years.

Planning for quality improvement monitoring adapted to local setting. Gain support from local/regional/national Ministry of Health. Supply enough training materials/clinical materials to local hospitals/clinics/birth attendants where protocols are expected to be implemented. And close communication and frequent follow-ups for refresher trainings are important!

If you are just starting out in your HBS training, partner with others who have had lots of experience.

Make local contacts before leaving for the trip, and make sure to know what everyone's role will be. Clarify whether you will be responsible for transporting all teaching materials and equipment.

Leave your expectations at home and go with the flow! Do not assume anything, ask! People really are trying their best, they have a lot of challenges and barriers that you and I have never faced. Be flexible! You will learn just as much as you teach—if not, more. And share with others!

Target geographies/facilities that are manageable and work with local leaders. Research and be aware of social/cultural/political conflicts in the local area and understand common biases. Do not just do a one-off training, you have to have a continued presence and a long-term plan. For example, an organization I work with has the goal of training and equipping all governmental-run medical staff. When complete we have a further goal of working with the medical staff to determine which Midwives should be trained as well as what principle all midwives should be taught. We started with teaching midwives and found that many are not very active and may only birth one baby in a year. These individuals will not practice as needed to maintain skills. However, teaching the first steps and much of the basic principles is important nonetheless.

Its vital to have the in-country Hospital administration, Ministry of Health and stakeholders' buy-in for the training. We have been going for five years and are well known and have an official agreement with the hospital– but it took a long time. Don't do one-off trainings—this does not support the local teams. And don't assume what you teach in a classroom will, translate into active ward care. If staff must miss work to attend training, they will likely not be paid, and may expect a small stipend and food during the training. They often travel far distances (1-2 hours) to attend training, so build in some funds in your budget to account for some of their expenses.

Having fewer participants generally means more time for practicing and more focused support from the trainers. So it can be good to aim for smaller numbers and more frequent courses, rather than large numbers of participants and fewer courses. Don't do a one-off training! Go back to the facilities to see how the training is being implemented (or not) and do 'refresher training' or simulation scenarios in the clinical areas if possible. This should be frequent!

Provide translated materials and leave enough equipment to allow others to provide training locally.

Develop a list of facilitator objectives and brief them well

Be familiar with the material ahead of time, practice, practice, practice!

Describe a completely unanticipated challenge you faced related to HBS training, and how you were able to overcome it.

I expected to be in resource poor locations. I was still surprised by exactly how limited resources were in some places--no running water, no electricity, no cord clamps or ties, etc. Talking with people about what they do and what resources are available is critical, and then design training to use what they can access.

Some things just do not go according to plan. The interpreters we had set up way ahead of time didn't show up, so we had to adapt as best we could. Though we were in a Portuguese-speaking country, we utilized our bilingual students, to provide the training in Spanish on day one. That night we hired new interpreters! It was a struggle for sure, but pivoted and triumphed! Our hired interpreters are now our life-long friends.

Teaching "check the heart rate" was a bit of a challenge. We taught only umbilical stump palpation for heart rate. Teaching the difference between "fast" (eg: faster than the provider's) heart rate and "slow" (slower than the provider's) heart rates, by having them palpate their own pulse along with the manikin's. Teaching how to tie a surgical knot on the cord, works better if you have 2 strings of different colors. That way they can see the direction that each string takes in forming the knot. One other learning device that worked well was having students list what they wanted to learn before the training started. We posted those ideas to on a chalkboard, then checked them off as we addressed each one through the training.

Be prepared for the unanticipated! I had been told by our partner organization I would be teaching ECSB but when I arrived, local organizers had been told I was to teach ECEB. I had not been given any materials for ECEB, but because I knew the course well, so I was able teach it. I was able to gather enough of needed supplies for students to share and we used the small baby mannequins. I managed to find paper so they could take notes. I gave them the HBS website address so they could see videos and other materials. It was an unpleasant surprise, but knowing the content well saved the day.

We had a major difficulty downloading the very impactful HBB resuscitation video in-country. I was not prepared how weak the internet access was in a city of 70,000 people. We were able to connect with a local tech-savvy healthcare worker who drove us to the internet café where we had a strong enough signal to download the video. This would have been completely avoided if we had downloaded it in the US prior to departure.

Literacy was an issue for our training. We didn't know our learners would not be able to read/write. Because of this, we emphasized role playing to teach the content. This also showed us how valuable the HBS Action Plans are, because they can be understood without reading.

When planning a training in Rwanda, we were told the learners could speak English. That was not the case... We started the course in English, but shortly after we realized most of the learners spoke the local language (Kinyarwanda) and French. Luckily two of our HBB master trainers and I spoke French.

We presented the course to neonatologists, but few health professionals that actually needed the training. We did one training in a rural area and the constraints there were mostly lack of equipment (ambu bags, mannequins for practice),

The matron of the neonatal unit had allocated herself to come to the course that day, but also to work on the ward. A few of the doctors were doing the same thing, as this was the only way the hospital could 'release them' and yet still have those wards covered medically. They therefore kept popping in and out. We overcame it for the doctors, by them going to the wards during the break times and we allocated one trainer to catch them up if they missed any of the training. For two of the doctors, who couldn't make it/enough of it, the matron and 2 other nurses, we ran a smaller course later on specifically for them.

During one trip, we had an abundance of physicians who all wanted to become Master Trainers (MTs). Some were better educators than others. We had laid out a plan for facilitator courses followed by provider courses where the new facilitators could be monitored teaching. We were there for 2 weeks of training. Unfortunately, people could not come as planned. Schedules changed, transportation issues, etc. So instead of doing a two day MT/facilitator training followed by 6 provider classes and a second facilitator training (taught by the newly trained MT), we were doing provider training and facilitator training simultaneously. Luckily we had several rooms we could use and we had an abundance of new facilitators. We divided up and had some of us (experienced MT) supervise the provider class with new facilitators teaching, and had another of us supervise a new facilitator-MT-to-be teaching a facilitator class in another room. Luckily we had enough equipment. On another trip, we did daily classes of 36 providers. One day we had 5 men in the class - motorcycle drivers! They pick up laboring women from small villages and drive them to the hospital - and sometimes they don't make it and the women deliver on the side of the road. AND, the men spoke an entirely different dialect from everyone else in the class. But we did find one midwife who spoke their dialect. So we had one table with 5 men (with NO medical knowledge) and one woman midwife as students and one MT from the US and one new local MT. And the men were amazing learners!

Describe the ways an HBS program is best supported before and/or after training(s).

Ongoing connection for information and problem solving after trainings is needed, either in country or remotely.

Best support: connecting locals with resources: Donors, community partners, & access to free resources on AAP.org (including the amazing videos by Global Health Media - so incredible).

Ongoing support through continued correspondence with learners. Going back to see what they still know and practice.

Provide support by compensating attendees, providing certificates, and snacks. Follow-up/refresher courses are also necessary!

After the training there needs to be a plan in place as to how the participants will practice skills. This can be through the use of a skills corner that is equipped, where healthcare workers practice at the beginning of each shift.

Important that HBS trainers adequately prepare for the course by reading the Provider Guide, reviewing the Flip Chart and Implementation Guide. Learners must review the Provider Guide. Afterwards, the trainers must debrief the course and review participant evaluations.

Ongoing practice/training. Re-enforcing practice and re-training of staff is necessary to achieve results.

Coordination with team before.

Debriefings pre and post.

Outline of expectations.

It is best, in my opinion, to have ongoing support and supervision. On-site there needs to be leadership, but there has to be support at all levels. Clinicians have to model behaviors and there have to be systems to support minds turning to HBB and ECEB protocols routinely. What will work best is usually site-specific, but I think it has to be incentivized at first.

Best ways to support:

Planning for quality improvement monitoring adapted to local setting.

Support from local/regional/national Ministry of Health.

Giving training materials/clinical materials to local hospitals/clinics/birth attendants where protocols are to be practiced.

Close and frequent follow-ups/refresher training.

Very important—Continued visits and retraining.

These are refresher courses I was attempting to implement. The healthcare workers had already been trained while in midwifery school, however had ZERO understanding of "recertification", which is an essential aspect to CPR, neonatal resuscitation, but not addressed in HBB.

Train the trainers to ensure support will continue.

Key actions:

Introducing instructors far ahead of the trip to establish relationships with learners in advance

Having a local point person to follow up with locally after the initial training.

Providing enough materials (posters, workbooks, NeoNatalies) to leave after training

Before:
Planning is essential!
Team leader must identify a local champion prior to the training.
Identify who the learners will be, their level of knowledge, what they actually do when a baby is born, barriers, etc.
Invite learners to the training with significant time for hands-on practice and learning.

After:
Team must continue to communicate with the local champion/ master trainer
Have local champions to gather data and share with trainers

HBS Champion: I think there needs to be a dedicated person representing HBS in an area.

Provide enough equipment for resuscitation and practice after the initial training. Make regular follow up visits to support providers.

Confirm that all people attending the training are clinical providers that actually attend deliveries on a regular basis.

Established relationships and regular return visits to in-country partners is necessary. Established relationships and regular contact allow us to work in the hospital and do delivery room-based teaching and ward based simulations before and after the training days. This helps transfer the knowledge gained during the course into real life scenarios and highlights the quality improvement cycle part of the HBS program too.

Clear 'rules' for what we can and cannot do. The ability for facilitators to practice teaching students with supervision before the traveling Master Trainers return to their home country. Maintaining appropriate ratios of students to facilitators/Master Trainers. We can't have more than 6 students to one facilitator but at the same time, we can't have 3 new learning facilitators and only 4 students. Ideally a return visit (in 6 months to a year) from Master Trainers so that teaching can be observed, evaluated, and helpful hints given as needed.

Dedicate adequate time for facilitator orientation. They will need to know how to prepare, teach, and assess course participants.

Before: Be fully prepared in advance

After: Stay in touch with in-country contacts

Frequent refresher courses and regular practice

Before: Plan in coordination with local health authorities AND hospital-based leadership

After: Advocate for understanding of providers' needs, and provisions necessary to support them among Hospital leadership

What does not work well in implementing and/or sustaining HBS training?

Costs can be challenging. Covering all the program costs and supplies can become costly. Although there are now trained HBS Master Trainers ready to teach and support additional participants.

Teaching HBS and Helping Mothers Survive (HMS) together can be challenging with regard to coordinating HBS recommendations and HMS recommendations. They initially did not always mesh (eg: "first minute belongs to the baby" vs. "administer oxytocin within the first minute").

It is difficult returning to sites to support ongoing education because staff turnover means that you wouldn't necessarily have the same learners again.

Be aware of local culture and holidays. Try to avoid conflicts like running a training during Ramadan.

It is difficult to sustain HBB skills over time without continued refresher trainings. We conducted the two HBB Master Trainer courses, however as a US-BASED HBB Trainer, I was not involved with HBB implementation throughout the state of Maharashtra. Implementation was expertly delivered by local Indian HBB Master Trainers with regular follow-up by NICHD researchers. One of the findings is that skills degraded over time. Ongoing practice is necessary to maintain skills after initial training (i.e. low-dose high-frequency practice).

Biggest challenges:
1. Not being able to return to the original training site for follow up
2. Choosing master trainers on observations alone. They must show desire and have the time necessary to dedicate to perpetuate trainings.
3. Staying in touch with local leaders to ensure future trainings are being organized. This is the most difficult one.

Sometimes you end up with more participants-per-trainer than expected.

Be prepared for challenges:
Short supplies
Communication challenges and language barriers
Training area and audiences are sometimes ill-prepared

What doesn't work? One-off trainings!

I do monitoring and evaluation for other organizations who drop in, do a training, then leave. They expect training to be self-perpetuating a year later after the initial training. Ongoing support has to be sustained before any clinical practices are positively impacted in the long term.

Recipe for failure: Not focusing on strategic implementation; failing to adapt quality improvement monitoring to local settings; and failing to provide leadership for local champions.

Participant obligations frequently make them unavailable to stay for the entire time necessary to complete an HBS course.

Doctors sometimes debate and discuss the details of care far too long. This diverts from the HBS training.

Lack of communication with sponsoring group.

Differing levels of medical education of participants can be a challenge. It is different to teach to more highly educated audiences (i.e. physicians), they wanted to go more in depth than the program is designed to do.

Host country did not have enough equipment for program to be sustainable in rural outlying healthcare centers.

We didn't know most of our audience/students were illiterate and spoke a native language (not Spanish). It was not possible to complete pre and post-tests because they were unaccustomed to the concept of testing.

1. If there is no support from hospital leadership, learners cannot prioritize the learning opportunity- they have busy jobs.
2. Starting a training without asking the learners what they actually do, the resources they have, the limitations they face (You must know this to tailor the information to the local needs)
3. Lack of follow up and/or lack of local champion
4. Lack of equipment- Learners will not be able to sustain the program if they do not have enough bag/masks in the facility

What's not working: The single biggest issue we have is providers focusing on Meconium and suction. It creates a debate on suction so much so that it delays resus and delays learning skills. In the facility, providers see a lot of meconium and time is wasted suctioning with no effect – it creates infection, injury, poor skills and poor focus, - it is the single biggest barrier to effectively starting a resus on a baby

Need more time (days) to conduct a course. Availability of resource materials at different levels

Challenges for local social practices, for example, knowing if you should start teaching on-time or respect cultural norms and start a little late.

Having too few OSCE stations at the end of the training - this led to too many people waiting and getting restless after the training was concluded.

It is often difficult to help local partners understand what we can and cannot do. Teaching a two-day course to make someone a facilitator and not supervising them in teaching, does not prepare facilitators to teach. By the same token, having too many new facilitators in a class is a challenge. We had way too many people who wanted to be facilitators or master trainers and not enough students to teach. We also did not have enough experienced Master Trainers to supervise them. Although we had laid out our needs during the pre-trip planning, it was clear once we arrived that expectations were misaligned from established goals.

Poorly orientated facilitators. Spend more time developing and supporting them!

Translation/language barriers are challenging. Time is always in short supply!

It was hard for us to train pediatric residents stateside in HBB, as they knew a lot of the core material already and thus became bored with the repetitive nature of the program (that being said, they are not the target audience, so it's not a fault of the program!).

One-off trainings don't work! A single training without some well-defined strategy for hospital-based re-enforcement of training will not change outcomes.

What works well in implementing and/or sustaining HBS training?

Have an ongoing in-country presence in some way. Develop a multi-year plan. Work closely with in-country partners to select birth attendants to become trainers.

Community partnerships and providing printed materials in local language are important!

Hands on component, teaching each other, getting learners involved in questions, suggestions, sharing experiences—all are helpful and necessary!

Make time for lots of practice and sharing clinical experiences

Ensuring that we worked with hospital leadership well in advanced and throughout the training so that they were able to allow staff to have time off from clinical work to attend the training, assisted with ensuring the equipment was maintained, and encouraged participants to regularly practice skills after the training. It was also helpful, at times, to have non-clinical participants who had leadership roles in the health care center/hospital to understand what the course was about and how important it is.

1) Collaboration with NICHD, who had researchers participate with us. There were two US teams, one for India and one for Kenya. 2) Interprofessional collaboration with both faculty (Nurses and Physicians) and learners (Midwifes, Nurses and Physicians). 3) We trained 2 separate groups in India during the week. For the second training, the Indian faculty were learners at the first training. There was a travel day between the two courses in Belgaum and Nagpur, India). 4) Both Indian faculty and the US faculty were great collaborators and we integrated faculty within each table of six. 5) We asked the learners at both courses: a. What will you remember about HBB?, b. What will you no longer do (when caring for babies after birth)?, c. What practices will you incorporate into your care at birth? 7) An article was published with all India, Kenya, US faculty and NICHD, entitled, Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time? (Bang et al, BMC Pregnancy and Childbirth (2016) 16:364 DOI 10.1186/s 12884-016-1141-3)

(1)Holding a separate Master Trainer day for those with the desire and initiative to be an MT. These were held on Wednesday, then the new trainers held mentored training on Thursday and Friday. (2) Returning to the site and holding more mentored trainings with the above new MT's and adding MT's as needed for the communities.

Practicing going through the entire book with the group and having a lot of hands on practice with bag mask ventilation

Work in small groups with a trainer; have adequate equipment for each learner; have enough provider guides for everyone in the native language; and have good interpreters

In our Uganda project we implemented HBB in 2012. We have volunteers at the facility frequently and we were able to "normalize" newborn resuscitation. We have extraordinarily low rates of newborn death, and both HBB and ECEB are a huge part of that. It took years to make it part of regular practice, but I believe it works because we had the ability to stay with it, normalizing it, modeling it.

Partner with local champions: Ministries of Health, NGOs, etc. And focus on Quality Improvement planning and implementation planning during initial training.

Observe the low trainer-to-learner ratio and use a "parking lot" to list questions and exceptions for discussion during the training.

Everyone should have a clearly understood role, and make sure to fully prepare the site of the training before attendees arrive.

Frequent, repeated practice is important

Provide regular follow up after the initial training to ensure skills are regularly assessed/reviewed and practice is ongoing.

Have 2 instructors (1 experienced mentor, 1 newer teacher); have local contacts to assist with managing materials/equipment; provide interpretation skills if needed; have a quiet space for training; and be sure to provide participants with lunch and snacks.

1. Get local leadership support (hospital, community, health ministry)
2. Involve local providers
3. Engage experienced leaders
4. Build a team that is willing and able to adapt
5. Follow up after initial training

It is critical to have community support and to also have an organization that can support continued training and review on the ground in your area. The biggest challenge isn't getting qualified teachers but having an ongoing administrative process for ongoing training.

The skills of basic bag and mask ventilation are best taught in classroom but must translate into real practice. Many variables can be managed, taught, and mentored; however, one of the biggest barriers is fear. So successfully building confidence is important. The biggest challenge is the lack of knowledge that the air is the single biggest interventions to save a baby. Many providers think old habits, and focus on secretions (and suctioning).

We developed a core of eight "HBB Champions". They wear special colored scrubs and are known as the HBB teachers in their facility. We also have a higher ratio of bag and masks than penguins (deliberately). There is a bag and mask beside every bed, and in a given day we may do 7-10 resuscitations. Some are simple stimulation, while others require bag & mask. We ALWAYS start resuscitations at the mother's bedside – in order to delay cord clamping.

We also keep a NeoNatalie in the labor ward. This is vital to capture medical students, student nurses, student midwives, senior OBGYN etc for impromptu teaching.

We also provide weekly refresher trainings by core midwives and give them ongoing encouragement. They are also provided with booklets that get stamped for their professional development. This makes them proud to attend the lessons.

Language can be a challenge some locations may require a bi/tri-lingual course. Ensure that the participants who need translation/interpretation are at the same table, along with a trainer who can translate. And be willing to change tables if it became apparent that a participant is struggling during the course. This requires that trainers really focus on teaching at the tables with the flip charts.

Engaging and mentoring participants is key! For example, on my second trip we trained 6 Master Trainers on day one and two. Then, those trainers taught with us for 8 days, teaching 36 providers each day. At the end of the two weeks there, the Master Trainers truly understood the HBS program and were independent in teaching. They have gone on to continue teaching since then.

Ensure your own team is prepared in advance of the training session. Work with Ministry of Health in the target country. And make sure to provide enough teaching supplies, materials, and equipment.

The two most important parts: lots of hands-on practice and developing a hospital-based coach/champion!

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