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Background Pre-exposure prophylaxis (PrEP) delivery to adolescent girls and young women (AGYW) is scaling up in sub-Saharan African countries. Understanding how AGYW learn about PrEP is needed to inform programs seeking to reach AGYW with HIV prevention tools. Methods AGYW (ages 15-24), attending routine family planning and maternal child health clinics in Kisumu, Kenya, participated in in-depth interviews. AGYW were recruited if they either declined or accepted PrEP when offered that day in clinic or were currently or previously on PrEP. Thematic analysis was used to identify key themes related to the type and quality of knowledge sources from which AGYW first became aware of PrEP. Results Overall, 140 in-depth interviews were conducted with AGYW. The median age was 21.5 years (interquartile range: 20.0-23.0), 65% of participants were married, and almost half (45.7%) were currently taking PrEP. Participants reported learning about PrEP from 3 primary sources: (1) clinic-based education; (2) friends, family, or other PrEP users; and (3) media and community outreach. Participants who reported learning about PrEP from friends or family were highly enthusiastic about PrEP. The accuracy and completeness of knowledge varied with most inaccuracies around the cost, dosing, and who benefits from PrEP. Community outreach campaigns provided fewer details, resulting in more inaccurate information and distrust of information received. Conclusion PrEP information reaches AGYW through many sources with variable accuracy and completeness. Training providers and peer leaders to disseminate thorough and accurate PrEP information when counseling AGYW could positively impact acceptance and proper use.

We sought to understand key influences on pre-exposure prophylaxis (PrEP) uptake among Kenyan adolescent girls and young women (AGYW) whose decision on PrEP use was misaligned with their risk for HIV acquisition. Semi-structured in-depth interviews (IDIs) were conducted with 47 Kenyan AGYW living without HIV aged 15–24 years who were offered PrEP during routine maternal and child health and family planning visits at four facilities in Kisumu, Kenya. AGYW were sampled from two groups: 1) declined PrEP and had ≥1 sexual partner(s) of unknown HIV status and 2) initiated PrEP and reported having one HIV uninfected partner. IDIs were audio-recorded, transcribed, and descriptively analyzed. AGYW with HIV uninfected partners chose to initiate PrEP to address fears of HIV acquisition due to known or suspected infidelity. AGYW with partners of unknown HIV status recognized PrEP as a helpful tool for protecting themselves against HIV, yet worried about their partners’ reactions and prioritized avoiding uncomfortable or unsafe situations over taking PrEP. Among pregnant AGYW, the responsibility of motherhood and providing a future for one’s family, through staying healthy and remaining HIV-free, was a strong motivator for initiating PrEP. Among non-pregnant AGYW who desired motherhood in the future, fears that PrEP could negatively impact fertility or reduce effectiveness of FP methods led to declining PrEP. Peers positively influenced PrEP decision-making, especially personally knowing a PrEP user. More studies are needed that examine strategies to enhance PrEP uptake through messaging and delivery approaches that are tailored to AGYW, including peer-led strategies.

Background During HIV retesting in antenatal and preexposure prophylaxis (PrEP) care, discrepant results occur, but guidelines are lacking. Methods In a Kenyan trial implementing antenatal PrEP, if 1 test is reactive, a second is performed; if discrepant, both are repeated; if persistently discrepant, DNA polymerase chain reaction (PCR) is performed. Results Among 4451 women, 23 265 HIV retesting sessions were performed; 14 (0.06%, 95% confidence interval, 0.03%–0.10%) had discrepant results among 10 individuals; in all 10 initial cases, PCR was negative. Conclusions Discrepant rapid tests are an expected, rare, and important challenge for antenatal care HIV retesting, with and without PrEP. Clinical Trials Registration NCT03070600.

We conducted a population-level short message service (SMS)-based survey among individuals aged 18–34 years in six HIV high-burden counties in Western Kenya to assess pre-exposure prophylaxis (PrEP) awareness, acceptability of non-facility PrEP delivery, and willingness to pay for PrEP. In January 2019, anonymous data were collected using mSurvey Inc., Nairobi, Kenya, which sends SMS messages via mobile provider networks to a ‘general audience’ pool of subscribers ≥18 years. Subscribers’ demographic information was matched to Kenyan census data by age, gender, and county. Of the 3825 individuals who received the survey, 2617 (68%) opened the survey and 2498/2617 (95%) completed all questions. Overall, 84% had ever heard of PrEP, of whom 59% demonstrated understanding of PrEP; understanding was greater among men than women (64% versus 55%, p

Summary Background Pregnant women in settings with high HIV prevalence are at increased risk of HIV acquisition and subsequent vertical transmission. We implemented and evaluated a novel programme to provide pre-exposure prophylaxis (PrEP) in maternal and child health clinics in Kenya. Methods In collaboration with Kisumu County Department of Health, we integrated PrEP delivery within 16 maternal and child health clinics in Kisumu County (Kenya). Women and girls older than 15 years seeking maternal and child health services who tested HIV negative at that visit or within a month and were willing to receive PrEP counselling were interviewed to assess for HIV behavioural risk factors and offered PrEP. Correlates of PrEP initiation and continuation were assessed using Poisson regression in univariate and multivariate analyses. Potential correlates included in our analyses were age, marital status, marriage type, whether pregnant or post partum, gestational age (if pregnant), and HIV risk factors in the previous 6 months. Reasons for the decision to discontinue after having decided to initiate PrEP were evaluated. Women who initiated PrEP were followed up 1 month, 3 months, and 6 months after initiation. Findings Between Nov 20, 2017, and June 13, 2018, 9376 pregnant and post-partum women were assessed for behavioural risk factors and willingness to initiate PrEP. Overall, 2030 (21·7%) initiated PrEP, and 2027 had the status of their partner captured (153 [79·3%] of 193 women with partners living with HIV, 1178 [37·2%] of 3165 women with partners of unknown HIV status, and 696 [11·6%] of 5997 women with HIV-negative partners). Predictors of PrEP initiation in the multivariate analysis were: being younger than 24 years (adjusted prevalence ratio 1·14, 95% CI 1·02–1·28); having a partner living with HIV (6·96, 5·46–8·89) or of unknown HIV status (3·08, 2·50–3·81); gestational age of less than 26 weeks (1·22, 1·02–1·47); having been diagnosed or treated for a sexually transmitted infection (1·57, 1·20–2·06); having been forced to have sex (1·82, 1·38–2·42); having experienced intimate partner violence during the previous 6 months (1·65, 1·10–2·48); having shared needles while engaging in injection drug use (2·43, 1·69–3·50); and recurrent use of post-exposure prophylaxis (1·96, 1·36–2·82). Overall, 786 (38·7%) of 2030 women who initiated PrEP continued use after the first month, with 104 (68·0%) of 153 women who had a partner living with HIV continuing use. Having a partner living with HIV was the only predictor of PrEP continuation at 1 month in the multivariable model (1·98, 1·54–2·55). Frequent reasons for discontinuation were side effects and low HIV risk perception. No incident HIV infection was reported among women on PrEP. Interpretation Many women attending maternal and child health clinics had risk factors for HIV and elected to use PrEP, indicating that routinely accessed maternal and child health clinics can be an effective platform for PrEP delivery for young women. As PrEP awareness rises, PrEP provision in routine clinical settings such as maternal and child health facilities might contribute to decreased HIV incidence among young women. Funding US Department of State.

In sub-Saharan Africa little is known about how often women use pregnancy self-tests or characteristics of these women despite evidence that pregnancy self-testing is associated with early antenatal care (ANC) initiation. Understanding the characteristics of women who use pregnancy self-tests can facilitate more targeted efforts to improve pregnancy testing experiences and entry into the ANC pathway. We conducted a cross-sectional survey among pregnant women enrolling in a pre-exposure prophylaxis (PrEP) implementation study to determine the prevalence and factors associated with pregnancy self-testing among women in western Kenya. Overall, in our study population, 17% of women obtained a pregnancy self-test from a pharmacy. Pregnancy test use was higher among employed women, women with secondary and college-level educated partners, and women who spent 30 minutes or less traveling to the maternal and child health (MCH) clinic. The most reported reasons for non-use of pregnancy self-tests included not thinking it was necessary, lack of knowledge, and money to pay for the test. Future research should focus on understanding the knowledge and attitudes of women toward pregnancy self-testing as well as developing community-based models to improve access to pregnancy testing and ANC.

Background Providing HIV self-tests to women for distribution to male partners may provide a unique opportunity to increase male partner and couples testing among women in HIV high-burden settings. Methods Between November 2017 and June 2018, we offered self-tests for at-home couples or partner HIV testing to HIV-uninfected women seeking routine maternal and child health and family planning services at eight facilities in Kisumu, Kenya. Women accepting self-tests were offered at least two self-tests (OraQuick) to take to their partner(s) with instructions on use. HIV self-testing (HIVST) outcomes were evaluated using available programmatic data. Results Overall, 3620 women were offered self-tests for at-home male partner HIV testing. The median age was 24 years (interquartile range 21-28) and 81% were in monogamous marriages. Overall, 1422 (39%) women reported having a partner of unknown HIV status, of whom 755 (53%) accepted self-tests. Among women with partners of unknown HIV status who declined self-tests (n = 667), 49% reported needing to consult their partner. Pregnant women were more likely to accept HIVST than nonpregnant women (prevalence ratio = 1.2, 95% confidence interval 1.0-1.4, P = 0.013). Self-testing outcomes were ascertained for 389 (44%) women who accepted self-tests. Among these women, 93% offered HIVSTs to their male partner; of these, 95% reported their male partners used the self-test and 99% used a self-test with their partner. Conclusion Among women attending routine maternal and child health and family planning services who had male partners of unknown HIV status, over half accepted self-tests for partner testing. Most women with outcomes ascertained reported that male partners accepted and used self-tests and that couples testing occurred.

Adolescent girls and young women (AGYW) in sub-Saharan Africa have high HIV incidence. Despite scale-up of programmatic delivery and demand creation activities in this population, pre-exposure prophylaxis (PrEP) uptake is low. To explore community perceptions around AGYW PrEP use, we conducted four focus group discussions (FGDs) between October and December 2018 with 26 Community Advisory Board (CAB) members in Kenya. Conventional content analysis and thematic network analysis were used to identify themes relating to community perceptions of PrEP use among AGYW. CAB members noted community perception of PrEP use as unacceptable for AGYW because of the potential to increase “promiscuous” behavior, STIs, and pregnancy. AGYW may face stigma if PrEP is mistaken for HIV treatment, and may fear HIV testing or accessing PrEP because of a lack of youth-friendly services. PrEP can be integrated into maternal and child health and family planning clinics, which are routinely accessed by AGYW and lack the stigma associated with HIV clinics. PrEP scale-up among AGYW will require continued community sensitization to address concerns, reduce stigma, and clarify misperceptions.

Background: Pregnant and postpartum women in high HIV prevalent regions are at increased HIV risk. Oral pre-exposure prophylaxis (PrEP) can decrease HIV incidence reducing infant HIV infections. Understanding healthcare worker (HCW) beliefs about PrEP prior to national roll-out is critical to supporting PrEP scale-up. Methods: We conducted 45 semi-structured interviews among a range of HCW cadres with and without PrEP provision experience purposively recruited from four clinics in Kenya to compare their views on prescribing PrEP during pregnancy and postpartum. Interviews were analysed using a conventional content analysis approach to identify key influences on PrEP acceptability and feasibility. Results: All HCWs perceived PrEP as an acceptable and feasible HIV prevention strategy for pregnant and postpartum women. They believed PrEP meets women’s needs as an on-demand, female-controlled prevention strategy that empowers women to take control of their HIV risk. HCWs highlighted their role in PrEP delivery success while acknowledging how their knowledge gaps, concerns and perceived PrEP implementation challenges may hinder optimal PrEP delivery. Conclusion: HCWs supported PrEP provision to pregnant and postpartum women. However, counseling tools to address risk perceptions in this population and strategies to reduce HCW knowledge gaps, concerns and perceived implementation barriers are required.

In a pre-exposure prophylaxis program for Kenyan women, we detected tenofovir-diphosphate in 61% (125/201) of randomly selected dried blood spots collected at the first follow-up visit. Tenofovir-diphosphate was detected more frequently among women who had partners living with human immunodeficiency virus, who were not pregnant, and who were ≥24 years.

Introduction The World Health Organization, while recommending pre‐exposure prophylaxis (PrEP) for HIV‐negative pregnant and postpartum women in HIV high‐burden settings, advocates for continued safety evaluation of PrEP in this population. Methods The PrEP Implementation in Young Women and Adolescents (PrIYA) program delivered PrEP to pregnant and postpartum women integrated within routine maternal and child health clinics (MCH) at 16 sites in Western Kenya. PrEP exposure and perinatal outcome data were collected among women obtaining postnatal services during programme evaluation. PrEP use was self‐reported and confirmed with clinical records. Perinatal outcomes including gestational age at birth, birthweight, congenital malformations and infant growth outcomes were abstracted from clinical records for mother‐infant pairs attending the six week visit. Associations between infant outcomes and maternal prenatal PrEP use were assessed using univariate and multivariate logistic and linear regression. Results The PrIYA evaluation identified 1530 postpartum mother‐infant pairs with data on prenatal PrEP exposure: 206 with prenatal PrEP use, 1324 without. Median maternal age was 24 years in both groups. PrEP users (any reported PrEP use) were significantly more likely to report HIV risk factors such as: intimate partner violence, sexually transmitted infections and having a partner with positive or unknown HIV status. Most mothers initiated PrEP during the second trimester (n = 116, 57%) and used PrEP for more than one month (n = 110, 58%). The mean birthweight was 3.3 kg and gestational age at birth was 38.5 weeks in both groups. There were no major differences between PrEP exposed and unexposed infants in rates of preterm birth and low birthweight. There were no congenital malformations identified in the PrEP‐exposed group and five reported in the PrEP unexposed group. At six weeks postpartum, infants in both groups had similar growth. No differences in infant outcomes were found by duration PrEP exposure, trimester of PrEP initiation, a subset analysis of women 15 to 24 years old or in multivariate analyses. This analysis demonstrates that monitoring of infant outcomes is feasible within large‐scale programmatic implementation of PrEP among pregnant and postpartum populations. Conclusions Pregnancy outcomes and early infant growth did not differ by PrEP exposure.

IntroductionWomen in regions with high HIV prevalence are at high risk of HIV acquisition during pregnancy and postpartum, and acute maternal HIV contributes a substantial proportion of infant HIV infections. Pre-exposure prophylaxis (PrEP) could prevent HIV during pregnancy/postpartum; however, identifying women who would most benefit from PrEP in this period is challenging. Women may not perceive risk, may not know partner HIV status and partners may have external partners during this period. PrEP offer in pregnancy could be universal or risk guided.Methods and analysisThe PrEP Implementation for Mothers in Antenatal Care (PrIMA) study is a cluster randomised trial that aims to determine the best model for PrEP implementation in pregnancy, among women attending public sector maternal child health clinics in Western Kenya (HIV prevalence >25%). Twenty clinics are randomised to either universal PrEP offer following standardised counselling (‘Universal arm’ 10 clinics) or risk screening with partner self-test option (‘Targeted arm’ 10 clinics). Four thousand women will be enrolled and followed through 9-month postpartum. The primary analysis will be intention to treat. Outcomes reflect the balance between HIV preventive effectiveness and avoiding unnecessary PrEP exposure to women at low risk and include: maternal HIV incidence, PrEP uptake, PrEP adherence, PrEP duration, ‘appropriate’ PrEP use (among women with objective evidence of potential risk), infant birth outcomes, infant growth and partner self-testing uptake. To better understand the feasibility and acceptability of the provision of PrEP in these settings, qualitative interviews and cost-effectiveness analyses will be conducted.Ethics and disseminationThe protocol was approved by the institutional review boards at Kenyatta National Hospital and the University of Washington. An external advisory panel monitors adverse and social harm events. Results will be disseminated through peer-reviewed journals, presentations at local and international conferences to national and global policy makers, community and participants.Trial registration numberNCT03070600.

Objective To assess the effect of a low-technology simulation-based training scheme for obstetric and perinatal emergency management (PRONTO; Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) on non-emergency delivery practices at primary level clinics in Guatemala. Methods A paired cross-sectional birth observation study was conducted with a convenience sample of 18 clinics (nine pairs of intervention and control clinics) from June 28 to August 7, 2013. Outcomes included implementation of practices known to decrease maternal and/or neonatal mortality and improve patient care. Results Overall, 25 and 17 births occurred in intervention and control clinics, respectively. Active management of the third stage of labor was appropriately performed by 20 (83%) of 24 intervention teams versus 7 (50%) of 14 control teams (P = 0.015). Intervention teams implemented more practices to decrease neonatal mortality than did control teams (P

Author(s): Cranmer, John N; Dettinger, Julia; Calkins, Kimberly; Kibore, Minnie; Gachuno, Onesmus; Walker, Dilys | Abstract: BackgroundGlobally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.Objective-methodWe compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.FindingsAlthough most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.SignificanceComparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade's intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.

Background Young women account for a disproportionate fraction of new HIV infections in Africa and are a priority population for HIV prevention, including implementation of preexposure prophylaxis (PrEP). The overarching goal of this project was to demonstrate the feasibility of integrating PrEP delivery within routine family planning (FP) clinics to serve as a platform to efficiently reach at-risk adolescent girls and young women (AGYW) for PrEP in HIV high-burden settings. Methods and findings The PrEP Implementation in Young Women and Adolescents (PrIYA) program is a real-world implementation program to demonstrate integration of PrEP delivery for at-risk AGYW in FP clinics in Kisumu, Kenya. Between November 2017 and June 2018, women aged 15 to 45 from the general population seeking FP services at 8 public health clinics were universally screened for HIV behavioral risk factors and offered PrEP following national PrEP guidelines. We evaluated PrEP uptake and continuation, and robust Poisson regression methods were used to identify correlates of uptake and early continuation of PrEP, with age included as a one-knot linear spline. Overall, 1,271 HIV-uninfected women accessing routine FP clinics were screened for PrEP; the median age was 25 years (interquartile range [IQR]: 22–29), 627 (49%) were, Kenneth Mugwanya and colleagues report on implementation of a pre-exposure prophylaxis programme for young women and adolescent girls at risk of HIV infection, in Kenya., Author summary Why was this study done? Adolescent girls and young women (AGYW) in Africa are disproportionately affected by HIV infections because of cultural, structural, biological, and behavior factors. Preexposure prophylaxis (PrEP), as a highly potent and recommended discreet user-controlled HIV prevention strategy, has the potential to substantially reduce new HIV infections in African women if delivered with high coverage and if used with sufficient adherence. However, data are limited on “real-world” implementation approaches to efficiently reach at-risk women who may benefit from PrEP. Family planning (FP) clinics provide care to young women at risk for acquiring HIV and have in-built staffing, supply chain, and HIV testing access, which could contribute to more efficient PrEP implementation with less cost, but no study has evaluated this model in “real-world” settings. What did the researchers do and find? We conducted a pilot open-label, “real-world” implementation program to evaluate the feasibility of integrating PrEP delivery into routine FP clinics to reach HIV at-risk young women. General-population women accessing FP services were universally screened for HIV behavior risk factors and were counseled for PrEP by program-dedicated nurses embedded in 8 public health FP clinics in a high–HIV-prevalence region in Kenya. We found that FP clinics can be an effective platform to efficiently reach HIV at-risk women who may benefit from PrEP. PrEP screening was feasible, and 22% of the general population of women took PrEP home. There was a high drop-off in early PrEP continuation (41% PrEP continuation at 1 month) particularly among AGYW

Maternal and neonatal mortality in Northern Guatemala, a region with a high percentage of indigenous people, is disproportionately high. Initiatives to improve quality of care at local health facilities equipped for births, and increasing the number of births attended at these facilities will help address this problem. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a low-tech, high-fidelity, simulation-based, provider-to-provider training in the management of obstetric and neonatal emergencies. This program has been successfully tested and implemented in Mexico. PRONTO will now be implemented in Guatemala as part of an initiative to decrease maternal and perinatal mortality. Guatemalan health authorities have requested that the training include training on cultural humility and humanized birth. This article describes the process of curricular adaptation to satisfy this request. The PRONTO team adapted the existing program through 4 steps: (a) analysis of the problem and context through a review of qualitative data and stakeholder interviews, (b) literature review and adoption of a theoretical framework regarding cultural humility and adult learning, (c) adaptation of the curriculum and design of new activities and simulations, and (d) implementation of adapted and expanded curriculum and further refinement in response to participant response.

Background Ineffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators. Methods Data was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement. Results A total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p

Purpose To assess the impact of an emergency obstetric and neonatal simulation-based team training program (PRONTO) on process indicators and maternal and neonatal outcomes. Research Questions Does PRONTO training improve participating providers’ obstetric and neonatal emergency knowledge, self-efficacy, and goal achievement? Do public hospitals in Mexico where providers receive PRONTO training have different maternal and neonatal outcomes than control hospitals? Significance Studies in resource-stable countries have found improved patient outcomes following participation in simulation team training. However, limited-resource countries, like Mexico, rarely have access to such trainings given the high cost of simulation. Acknowledging the potential for low-tech, highly-realistic simulation in resource-limited settings, PRONTO was piloted in 2009. Its impact on patient outcomes has yet to be evaluated. Methods We implemented a matched cluster, quasi-randomized trial of PRONTO training in 24 public hospitals in 3 Mexican states from 2010 to 2012. Intervention hospitals (n = 12) had selected providers (n = 450) participate in PRONTO training. Providers were trained in 2 modules, 2 to 3 months apart focusing on the topics of neonatal resuscitation, obstetric hemorrhage, preeclampsia/eclampsia, shoulder dystocia, teamwork, and communication using obstetric emergency simulations, guided debriefings, skill stations, and team-building exercises. Data collection included baseline facility inventory and chart review, pre-post intervention individual participant testing, and 12 months of follow-up, chart review, and birth observations. Pre-post process indicators were analyzed using linear regression. Outcome data were analyzed using negative binomial regression with a difference-in-difference approach for the 3 months prior to data collection at 4, 8, and 12 months follow-up non-cumulatively. Results Following PRONTO training, knowledge and self-efficacy for physicians and nurses (P