Colonial history has deeply influenced the structures that govern global health. Though many curricula promote equity, few focus on developing competency in understanding and dismantling colonialism, and the structural barriers to global health equity. To dismantle colonial structures and create equitable collaborations, learners must be able to recognise how colonialism permeates global health practice. We propose a praxis cycle in education that asks learners to actively engage with these concepts. The praxis cycle includes: Theory: Learners explore the principles of decoloniality to understand how attitudes and practices are shaped by biased social structures influenced by colonialism. Reflection: Learners reflect on their work in LMIC settings through a lens of decoloniality and positionality. Action: Learners work in LMIC settings where they apply and actively engage with these concepts and insights. During implementation of this curriculum, we encountered several challenges including the cognitive dissonance of the learner to changing mental models of global health practice, existing systemic barriers to changing one’s practice and the development of accountability mechanisms for learners in this type of curriculum. Intentionally incorporating a praxis cycle helps learners recognise their role in disrupting the structural forces that promote inequities, and actively dismantle the forces upholding systemic oppression.

The current movement to ‘decolonize’ global health aims to both dismantle colonial frameworks that perpetuate inequity and racism, as well as to rebuild and uplift structures and systems that celebrate indigeneity. However, it is critical to recognize that teaching decoloniality within global health education is more than just the acknowledgement that there are key paradigms missing from current global health education. It is imperative to have a methodology to hold ourselves and our learners accountable to progress in practices and ideals that promote equity-based praxis. In this paper, we propose the creation of a tool to assess learner levels and their progression over time in both recognizing the impacts of colonialism and acting to transform their own global health praxis towards equity and decoloniality.

Background: Pediatric early warning (PEW) scores represent a “track-and-trigger system” that identifies clinical deterioration in a patient’s condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. Implementation: The PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool. Evaluation: The PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses’ knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses’ feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support. Discussion: Implementation of PEW scores increased nurses’ technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff. Key Findings Nursing staff felt more empowered to communicate clinical findings to the physician team following the Pediatric Early Warning Score for Resource-Limited Settings tool training and implementation process. The process of implementing the tool triggered more calls from nursing staff to the physician teams to initiate early intervention. Key Implications The Pediatric Early Warning Score for Resource-Limited Settings tool has the potential to improve competency and confidence of nurses in their triage capabilities. Although traditionally implemented in tertiary care centers, program managers should consider implementing this tool at the district hospital (secondary) level as well. Physicians and nurses both play crucial roles in triaging systems. Therefore, program managers should consider engaging both groups with the tool before and during implementation.

Background: Adolescents make up roughly a quarter of the population in Zambia; however, most nutrition-related programming is targeted at the under-five population. Understanding the scale of undernutrition in older children and adolescents is fundamental to alleviating food insecurity and addressing undernutrition across all age groups.Methods: A cross-sectional survey was performed in four low-income, peri-urban compounds in Chilanga District which included anthropometric measurements of children between ages 6 months-19 years and a household-level diet diversity and food security questionnaire. Wasting was used for children under 5 and thinness for children 5–19 years. Descriptive analysis and multivariate logistic regression were conducted to quantify the prevalence and distribution of malnutrition and understand the impact of food security.Results: We surveyed 393 households and 1,004 children between the ages of 6 months and 19 years. Children aged 6–9 years had the highest prevalence of severe thinness (5.2%) and adolescents (10–19 years) had the highest rates of moderate thinness (6.5%). Across all age groups, more than 75% of children were in households that worried about running out of food in the previous month. 24.9% of adolescents and 28.4% of older children were in households were more likely to go a whole day without eating compared to 16.9% of children under 5.Conclusion: Our survey indicated that malnutrition in adolescents and older children living in Chilanga district was comparable to those under 5. Interventions to address undernutrition must be targeted at older children and adolescents in order to ameliorate this burden.

Introduction Critical questions remain about COVID-19 vaccine effectiveness (VE) in real-world settings, particularly in middle-income countries. We describe a study protocol to evaluate COVID-19 VE in preventing laboratory-confirmed SARS-CoV-2 infection in health workers (HWs) in Albania, an upper-middle-income country. Methods and analysis In this 12-month prospective cohort study, we enrolled HWs at three hospitals in Albania. HWs are vaccinated through the routine COVID-19 vaccine campaign. Participants completed a baseline survey about demographics, clinical comorbidities, and infection risk behaviours. Baseline serology samples were also collected and tested against the SARS-CoV-2 spike protein, and respiratory swabs were collected and tested for SARS-CoV-2 by RT-PCR. Participants complete weekly symptom questionnaires and symptomatic participants have a respiratory swab collected, which is tested for SARS-CoV-2. At 3, 6, 9 months and 12 months of the study, serology will be collected and tested for antibodies against the SARS-CoV-2 nucleocapsid protein and spike protein. VE will be estimated using a piecewise proportional hazards model (VE=1−HR). Baseline data From February to May 2021, 1504 HWs were enrolled. The median age was 44 (range: 22–71) and 78% were female. At enrolment, 72% of participants were seropositive for SARS-CoV-2. 56% of participants were vaccinated with one dose, of whom 98% received their first shot within 4 days of enrolment. All HWs received the Pfizer BNT162b2 mRNA COVID-19 vaccine. Ethics and dissemination The study protocol and procedures were reviewed and approved by the WHO Ethical Review Board, reference number CERC.0097A, and the Albanian Institute of Public Health Ethical Review Board, reference number 156. All participants have provided written informed consent to participate in this study. The primary results of this study will be published in a peer-reviewed journal at the time of completion. Trial registration number NCT04811391.

Background/Objectives: Migrant children in family detention facilities often experience frequent relocations and prolonged stays in precarious living conditions. This frequent relocation results in fragmentation of necessary medical care, leading to delays and inadequate medical care. We aim to highlight the critical need for comprehensive medical documentation in immigration detention facilities, a fragmented health care system and potential harm to these children without appropriate medical documentation. Methods: We conducted a retrospective review of 165 medical records from children detained at the Karnes County Family Residential Center between June 2018 and October 2020 to evaluate the adequacy of pediatric medical documentation in an Immigration and Customs Enforcement (ICE) family detention facility. Specific areas of interest included acute care, nutrition, immunization, developmental screening, and tuberculosis screening. Simple descriptive statistics were used to analyze the data. Results: Only 25% of 418 acute medical care visits included specific diagnoses. There was no documentation regarding follow-up recommendations upon release. 97% of children had a chest X-ray completed for tuberculosis screening, however no follow-up recommendations were documented for those with granulomas. Vaccination histories were inconsistently documented. No nutritional categorizations were completed despite 16% of children being at risk for malnutrition or already malnourished. Conclusions: Our findings revealed significant gaps in documentation, particularly in medical decision-making and clinical reasoning. In a fragmented medical system, inadequate documentation can result in avoidable errors in diagnosis and management. Improving documentation practices is crucial to ensure that all children, regardless of immigration status, receive quality healthcare aligned with national and international standards.