Pediatric assessment and early resuscitation capacity building: Multi-country implementation of the StART Training-of-Trainers Model in Rwanda, Uganda, and Nigeria

Child mortality remains marked by profound inequities in sub-Saharan Africa, where many deaths occur within the first 24 hours of hospital admission due to delays in recognizing and managing critical illness. Access to practical, context-appropriate pediatric resuscitation training is limited, contributing to disparities in the quality of emergency care. The Systematic Assessment Resuscitation Training (StART) course was developed to address this gap through a one-day, multidisciplinary pediatric Basic Life Support (BLS) program with an embedded Training-of-Trainers (ToT) model, promoting sustainability. A mixed-methods pilot evaluation was conducted in three African countries: Uganda, Nigeria, and Rwanda. Quantitative data from pre- and post-course multiple-choice tests and BLS skills assessments measured knowledge and competence. Immediate and follow-up surveys captured participants' perceptions of relevance and confidence, as well as self-reported application of learning in practice. Qualitative data from open-ended responses were analyzed thematically. A total of 134 participants completed the StART course, including nurses, doctors, and anesthesia providers, with 14 completing the ToT program. Knowledge scores increased significantly across all sites (mean improvement 3.4 points on a 15-point test scale; p < 0.0001), with all participants meeting BLS competency standards. Gains were consistent across professions and countries. Follow-up surveys (response rate 67%) indicated participant-reported application of learning in clinical care, with perceived improvements in confidence and teamwork. Trainers described the ToT model as practical and achievable within local resource constraints. The StART pediatric resuscitation course was feasible, acceptable, and effective across diverse African hospital contexts. It demonstrated measurable learning gains and practical competence, alongside early participant-reported indications of improvements in teamwork and application of learning in clinical practice. The ToT model presents a promising approach to sustainable, locally led resuscitation training. Further evaluation is needed to assess long-term skill retention, institutional uptake, and impact on patient outcomes.