Exploring learners’ perspectives of a Project ECHO palliative care education curriculum in resource-limited settings in light of key learning theories

Background: Project ECHO (Extension of Community Healthcare Outcomes) is a well-established telehealth educational platform developed to improve access to specialist care training in underserved areas. The objective of this study is to explore the learning experiences of participants in a Project ECHO targeting care providers in India and explore considerations for how ECHO programs could be modied to cater to the unique learning needs of individuals in low- and middle-income countries. Methods : We implemented a one-year Project ECHO on pediatric palliative care (ECHO PPC) targeting healthcare providers in India. The program consisted of 24 bi-weekly sessions (March 2018-February 2019) hosted by the Hyderabad Centre for Palliative Care in Hyderabad, India. Learners who attended at least 20% (5 sessions) were eligible to participate. Data related to demographic characteristics of ECHO PPC participants were collected. Four focus groups were conducted (February-April 2019) either online via videoconference or in person. Focus groups recordings were transcribed, coded and independently veried. The codes were then arranged into overarching themes. Results : Thirty-six learners were eligible and invited to participate in the study. Seventeen individuals completed the study. Following coding and analysis, two major themes and seven sub-themes were identied. The themes included: (1) Benets of participation in ECHO PPC (creation of a community of practice; opportunity to exchange cultures, ideas and experiences; supportive role of the facilitator and peers; increased relevant knowledge and skills; and access to additional learning resources) and (2) Barriers to participation (diculties with time and practice schedule management and language and sociocultural factors). Conclusion: The key principals of learning theories were incorporated into forming the Project ECHO conceptual model in this study. PPC Project ECHO facilitated community building, stimulated professional interest and additional learning outside of the program. However, addressing the barriers and challenges might likely enhance the success of the program in future.

educational needs of practicing health professionals is an important step to improve access to palliative care for children living in resource limited settings, however, there are very few health professional training programs in LMICs that have incorporated training about pain management or palliative care into their curricula (9). In a previous study of pediatric physicians in South India, 87% strongly believed that more training in pediatric palliative care was required in postgraduate training curricula (10).
Project ECHO (Extension for Community Healthcare Outcomes) is an educational model which focusses on bridging the gap between community-level health care providers in underserviced areas and specialists (11). ECHO teaching sessions are conducted online via videoconferencing, at regular intervals (e.g. weekly or every 2 weeks) and follow a structured format of didactic teaching combined with case discussion involving all participants. Using technology-enabled learning addresses the burden of learners needing to miss work and travel to training, barriers that are particularly relevant in LMICs (8, 12,13). Thus, ECHO has been proposed as an effective strategy to address the need for pediatric palliative care education in LMICs, which can address the gap in current medical practice and knowledge in remote and under-resourced locations (14). There have been several studies describing the impacts of ECHO on practitioners' knowledge and self-e cacy and patient outcomes in high income settings (14,15). There are no studies investigating Project ECHO in LMICs, which is especially relevant given the growing interest to implement Project ECHO in these settings.
Several learning theories have previously been used to explain how the design of Project ECHO facilitates participant learning: social cognitive theory, situated learning theory, and community of practice theory (16). To date, only one study has explored the role of learning theories in an ECHO program (17).
Understanding the mechanisms that enable health care providers to learn through Project ECHO in LMICs is a critical step towards developing curricula that address the diverse and unique learning needs of individuals in these settings.
The objective of this study is to explore the perspectives and experiences of learners who participated in an ECHO program on pediatric palliative care in India, speci cally exploring their experiences related to key learning theories. We hope that this study will guide considerations for how ECHO programs can be developed to meet the unique learning needs of healthcare providers in LMICs.

Setting
We implemented a one-year ECHO program on pediatric palliative care (ECHO PPC) targeting healthcare providers in India. The ECHO PPC included 24 sessions, occurring every 2 weeks, between March 2018 and February 2019 hosted by the Hyderabad Centre for Palliative Care in Hyderabad, India. The curriculum design was informed thorough a literature review, surveys from stakeholders, and consultation with experts in the eld of PPC. Each ECHO PPC session was 90 mins in duration and involved a 20 to 30minute didactic presentation led by an international expert, followed by a clinical case presentation from a learner, and then group discussion of the case. The sessions occurred over Zoom, a multi-point videoconferencing software and were video-recorded and made available to learners after each session.
Additional learning resources (journal articles, presentations, videos) were shared with learners via email and social media after each session.

Study Participants
Learners who had attended a minimum of ve (21%) ECHO PPC sessions were invited by email to participate in a focus group to explore their perspectives and experiences with ECHO PPC. Demographic and professional practice characteristics of study participants was collected. Focus groups occurred between February and April 2019 (after ECHO PPC had nished) and were facilitated by one study author (MD). Each group contained 3-8 participants and were conducted either online (via Zoom) or in person.
Participants were assigned to focus groups based on their availability. Prior to conducting the focus groups, the three authors (MD, EE, DA) developed a focus group guide (Table 1) which explored participant experience informed by relevant learning theories. All focus groups were audio-recorded and transcribed verbatim. Thematic analysis (18) of the focus group data was conducted for this qualitative descriptive study. The original transcripts were rst coded by one author (EE) and then veri ed independently by the principal investigator (MD) and a research assistant (SM) to ensure consistency and accuracy in coding. The initial coding scheme was inductively developed by the team and updated throughout the analysis as the team's familiarity with the data grew. Lastly, concepts of learning theories were used to inform the organization of codes into larger themes and subthemes.

Participant Characteristics
Thirty-six learners were eligible and invited to participate, and seventeen of these individuals completed the study (Figure 1). Participants represented three healthcare professions from a variety of practice setting across India and Bangladesh (see Table 2). Each focus group lasted approximately 60 minutes.  Themes Two major themes containing seven sub-themes (Table 3) were identi ed through analysis of the focus group transcripts. These bene ts fall into ve subthemes: creation of a community of practice; opportunity to exchange cultures, ideas and experiences; supportive role of the facilitator and peers; increased relevant knowledge and skills; and access to additional learning resources.
Creation of a community of practice. The sense of community and opportunity for networking afforded by ECHO PPC was a salient theme across all four focus groups. Becoming members of a worldwide community of learners was a meaningful aspect of participants' experiences. Participants 16 and 10 mentioned this, "So, actually, I feel that I am in a community. This is more like a classroom and I can attend or share my knowledge or my experiences with another person or another people that are sitting in a different country. I feel that we are sitting in one room. I do feel that. I think it is good that I feel I am in the community in learning from different countries", "I think that all of the regular participants, so when I saw Dr. X for the rst time in Bangladesh, I didn't feel like I was a stranger or anything. We knew each other for one year on the ECHO platform and it's kind of helped us to speak easier". In keeping with the theme of community, Participant 6 added "I felt like a family. When Dr. X [the ECHO facilitator] calls on me and asks what my name is, we feel very welcome". Participants reported that they would like to go back to the built community and continue their collaboration, participant 14 stated "Once the program is done, we feel that we want to go ahead and continue and do something else so that we can keep on having ties". This also was the case for Participant 10, who revealed that "We constantly sit together after the ECHO sessions. We discuss ourselves and [watch the video of] that session later and then apply it to the job".
Moreover, networking with other care providers both within their own country and internationally built opportunities for sharing knowledge and resources outside of the ECHO platform, as described by Participant 10: "I feel my network has grown a lot more after the ECHO. I got introduced to a lot more people and that will help me to contact them directly".
As members of healthcare teams, participants also considered participating in the community of practice as a form of continuing medical education to be an integral aspect of their professional identity. Participant 16 summarized this idea, in the following way: "To treat my patients, I have to gain knowledge… I have to attend ECHO session or from wherever I gain knowledge, I have to attend those things. That is my responsibility, to do my job properly".
Opportunity to exchange cultures, ideas and experiences. The role of culture, ideas and experiences exchange was emphasized in most participants' comments. For instance, Participants 2 and 8 mentioned "We are different people from different culture, and the culture is not matching with everybody or the culture is not the same. Sometimes I de nitely feel comfortable to raise issues regarding what we are doing in our country to compare with other countries. I think it's rational and it's helpful", "There are cultural differences and similarities that have yet to be explored, and these ECHO sessions are very helpful for that".
In addition, ECHO PPC provided a platform for sharing ideas as summarized by Participant 10 "What kept us going was that most of the topics were from an international western view. Presenting cases from mostly an Indian and Bangladeshi background kind of brought in the discussion of how we could adapt the same things to our context. That's why ECHO was very good for me". The curiosity that participants shared for cultural diversity in psychosocial care were re ected by Participant 14: "Some of the things we've learned coming from the Western world, how can we apply them in the India or Bangladesh context? It's not true that these are good for the West and not applicable in India… Many people say "but people don't want to remember [their child after their death]", and I'm not sure! There are cultural differences and similarities that have yet to be explored, and these ECHO sessions are very helpful for that".
Participants also noted that their involvement in ECHO PPC could impact their broader local professional network, as they identi ed opportunities in practice to share their newly acquired knowledge with colleagues who were not part of ECHO PPC. Participant 16 summarized: "there are lots of physicians that are not aware enough to use opioids…So I take this opportunity as my responsibility to make aware all of the physicians that it's a good drug and you can prescribe it and how to prescribe it… Like this, when I get some shots of knowledge, this is my responsibility to aware other physicians who are not very familiar with these types of knowledge".
Supportive role of the facilitator and peers. Having supportive facilitators and peers who are from the same culture and speak the same language emerged as an important theme. As Participant 5 stated "We could understand her (the facilitator), she directs everybody, after nishing session, she summarizes the whole session if anyone didn't catch sometimes", and Participant 11 continued "She connects people. She introduces the other people who join in the ECHO, … (the facilitator) is from India, so there is coordination and English translation. It's helpful for us to understand". Participants also highlighted the signi cant role of other peers to encourage them to participant in their training sessions.
Increased relevant knowledge and skills. Participants highlighted the importance of gaining new knowledge and skills relevant to pediatric palliative care. Participant 11 mentioned "I think I choose this ECHO session to learn about more and increase my skills and knowledge regarding pediatric patient management". In addition, Participants 6 and 8 added respectively, "we can learn from the different people's perspectives. The worldwide teachers that teach us through these ECHO sessions", and "the sessions give me the oor to learn new things in pediatric palliative care. After the case presentation there is a group discussion which is helpful. These have helped me a lot to learn new cases. I am so happy because pediatric palliative care is new for me." Improved communication skills were regarded as a particularly valuable. Participant 1 commented: "Before the ECHO session, I have a fear and feeling that I could not communicate with children… By the ECHO session, now I know how to communicate with children and how to talk with their parents about death and the prognosis. This is the most important thing that I learned from the ECHO". Similarly, Participant 5 added "The most important thing that helps us a lot is building relationships with the children and the family…, from my perspective, it really helps us a lot to get in touch with the kids because kids are not always like adults. So, to get near to the kids and reduce their symptoms, the ECHO sessions really helped".
Many participants had some experience with adult palliative care and recognized the fundamental differences in the knowledge and skills which are needed to manage children with life-limiting illnesses. As participant 17 noted, "It's really very important for us because at a centre like in Bangladesh, we started to do pediatric palliative care very recently. We have a separate ward for that but unfortunately, we were not very focused with the pediatric palliative patients before. So, when we got attached with ECHO, it became very easy for us to relate with the patients at the centre".
Access to additional learning resources. Participants reported that access to additional educational resources which were provided after ECHO sessions lead to increased con dence, reduced feelings of burnout and stress, and improved health outcomes for patients. Participant 12 stated, "Working in palliative care, there is a thing called burn out, and working with pediatrics patient is the big thing…When I deal with pediatric patients, I feel stress more because there is a need to handle the pediatric patient and also the parents and there is more stressful work… If I don't know about pediatric palliative care, how do I give support? I feel more stressed. But now, when I see my patients, I know how I can help them and the parents, how I can remove their anxiety and some of my fears. Now I feel that my stress is reduced".

Theme 2: Barriers to participation
Analysis of the focus group data revealed that some participants encountered barriers to participation in ECHO PPC sessions. These barriers fell into two subthemes: di culties with time and practice schedule management and language and sociocultural factors.
Di culties with time and practice schedule management. The most common challenges noted by participants revolved around time constraints and managing hectic practice schedules to attend ECHO PPC sessions. For example, Participant 4 summarized "From 9-5 we have to cover our patients, home care we have to attend, we have to go for lunch also and we have to attend ECHO Sessions, and team meetings, and case presentations….We have to go here and there and we have to update everything, there are a lot of people suffering". Similarly, Participants 11 stated "coming to a monthly session is okay, but with 2 meetings each week on our side, and of course locally we have to attend so many meetings, sometimes from health commissioner, so we have to do all of those things".
In the event that participants could not attend all ECHO PPC sessions, some participants reported that missing sessions created negative emotions including stress and guilt. Participant 8 recalled "I wanted to make that time, but it was very di cult for me. I would get caught up in so many things" and Participant 10 summarized the notion by "A couple of times, those days were really critical, and I couldn't make it for the session. It was just not possible. Then you would feel bad that you missed this. That would really bring stress because you missed out. That reminds me of the session where I were supposed to have a Zoom call and I slept, I got up in the middle of the night and started messaging [the facilitator] and didn't fall asleep the whole night because I was so panicky".
Language and sociocultural factors. Participants highlighted that there were some barriers related to language and socio-cultural differences that made it challenging to communicate their PPC knowledge to others or to take the most from the sessions. Participant 5 stated that "English is a barrier. So, I can translate some slides in Bangla (Bengali language) and I can also share some videos. The videos are in English, but I can translate for them". Participant 3 added: "When we are talking with each other, it is easier to understand. During the actual session when we are participating in ECHO, it is somehow di cult to understand, due to rapport or uence, the language, the way you are talking… maybe that is the only di cult part".
A reluctance to speak in the group setting due to shyness emerged as another challenge participants faced. Participant 11 recalled "I was feeling shy because we didn't know each other" and Participant 15 added that her preference was to "type [questions] out because sometimes you aren't looking nice on the screen; sometimes it's actually a good idea so that everyone can catch your question". The reluctance to standing-out during the sessions was described in further detail by Participant 12: "Sometimes we are not comfortable and wonder if we should ask the question or not. In our culture, sometimes there are some barriers. Sociocultural things [are] an important part of our centre and culture, but sometimes it is uncomfortable for us".

Discussion
We describe the key ndings from our ECHO project describing the experiences of learners who participated in a one-year series of online series of learning sessions on pediatric palliative care focused on healthcare providers in India and Bangladesh. Participants identi ed bene ts and barriers to participation, which support key principles from learning theories including Social Cognitive Theory, Communities of Practice, and Situated Learning Theory, which have previously been used to explain how the design of Project ECHO facilitates participant learning (17).

Social Cognitive Theory
In Social Cognitive Theory, learners must believe in the bene ts of a new knowledge or skill for the learning exercise to be effective (19). In line with this theory, learners in our study identi ed a number of bene ts to participation in ECHO PPC, including: (1) creation of a community of practice, (2) opportunities for networking, (3) increased knowledge and skills, and (4) access to educational resources. Despite the barriers to participating, participants found the program helpful and consistently stated a strong desire to learn as their primary reason for enrolling in ECHO PPC and for continuing to participate. In Social Cognitive Theory, learners gradually develop con dence to apply the new behavior or practice, and are more likely to engage in new behaviours if they are con dent in their ability to carry out the new behaviour and are positively reinforced by in uential individuals (19). We found that the bene ts of the ECHO educational experience were not restricted to individual learning during the sessions; as participants reported that ECHO stimulated additional team learning outside of the sessions, with multiple participants mentioning instances when they relied on team discussions after the ECHO sessions to consolidate their learning. These additional learning activities may lead to enhanced learner con dence and provided positive reinforcement of new behaviours. Applying knowledge from our lessons to patient care in the workplace was more direct than we had initially assumed. Participants also reported downloading the additional resources and directly referencing them when making clinical decisions. In this way, ECHO PPC resources became essential tools in participants' clinic practices. Participants also identi ed the bene ts they derived from the supportive role of the ECHO facilitator. Highlighting how the facilitator would summarize each session's key messages and this improved their understanding during ECHO sessions. This key support may also contribute to participants' con dence and feelings of support in performing new behaviours.

Community of Practice Theory
Community of Practice Theory suggests that collaborating with peer learners and experts in a community is an effective learning strategy (20). Communities of practice emphasizes the importance of learning in a group, as the learning capacity of individuals increases when learning happens in a community (21). This theory emphasizes the importance of collaborative learning through mentoring and encouragement by peers and experts (17). Participants noted the importance of the support and empathy that they received from other peers through discussing challenges they have similarly encountered, noting that this was especially helpful when approaching di cult cases in their personal practice. Participants in our study described a sense of community had emerged among learners which helped them remain engaged and motivated throughout the program. Even after completing the program, participants felt connected to other group members and expressed a desire to maintain connections and continue collaborating with one another. Participants noted that the support and encouragement received from the ECHO PPC facilitator was helpful in reducing their stress and shyness and enhancing their participation. Participants described the barriers to participation in the learning community including shyness during the sessions, cultural differences in communication styles and not wanted to be perceived as outspoken or interruptive by the group. The facilitator's role was noted as central in building the sense of community and overcoming participants' barriers to participation, by connecting people during the sessions and ensuring that all participants felt they had an important role in ECHO sessions. The fact that the facilitator was from India was identi ed as positive since this allowed learners to feel more at ease asking questions. Facilitators were important in easing participants into discussions when natural conversation cues were di cult to identify.

Situated Learning Theory
In Situated Learning Theory, teachers provide learners with opportunities to improve their skills and knowledge and to simplify tasks to be more manageable. Learners must have the opportunity to engage their own interests which motivate them to learn (22). We found that participants were motivated to participate in ECHO PPC as they believed that the program improved their con dence in providing pediatric palliative care for their own patients. Learners' were positive about the learning, as they noted that their learning needs were incorporated into ECHO PPC through clinical case presentations and discussions with peers and experts. Learners highlighted the value of ECHO PPC sessions in exploring differences and similarities between Western approaches and those solutions which are suitable for India and Bangladesh.

Conclusions
The key bene ts which healthcare providers participating in a technology-enabled learning program on pediatric palliative care (Project ECHO) identi ed include creation of a community of practice, opportunities to exchange ideas, support from other participants, increased knowledge and skills as well as access to additional learning resources. Key barriers to participation included di culties with time and practice schedules and language and sociocultural factors. Additional barriers including access to technology and poor internet connectivity were also identi ed and should be considered when implementing technology enabled learning. Understanding the experiences of ECHO participants may allow educators to better understand the key drivers of learning and thus improve the design and implementation of ECHO projects focused on the learning needs of health care providers in resourcelimited settings.

ECHO-Extension of Community Healthcare Outcomes
LMICs-Low-and middle-income countries Study Participants Flow Diagram