Technological advances allow for increased international collaboration within the medical community (e.g., internet, e-mail, instant messaging, video-teleconferencing [VTC]). Partnering with clinicians and researchers across the globe allows for shared resources, particularly beneficial for underserved populations and communities with poor access to specialty resources, including neuropsychology. Along with the potential benefits of such collaborations comes challenges including language, cultural, and physical barriers. The presented findings detail important lessons learned from an ongoing research collaboration between the Einstein team (Bronx, NY) and a research group in Kerala, India, called the Kerala Einstein Study (KES), a study evaluating pre-dementia syndromes in Indian older adults. Here we highlight the training process of research assistants administering neuropsychological measures to older adults in India, by neuropsychologists in the USA.

One study manager and several research assistants (collectively referred to as RAs) based in India were trained by the first author, a neuropsychology postdoctoral fellow (MS) based in the US via VTC (i.e., Zoom), under supervision of a clinical neuropsychologist. RAs were trained in test administration and scoring for a variety of neuropsychological measures. RAs speak Malayalam and English; training occurred in English. Following training, VTC meetings were held to process testing experience and channels were created for ongoing administration/scoring questions and concerns (i.e., email, WhatsApp). RAs scanned and uploaded scored protocols to a protected web-based platform. MS double-scored several protocols and additional VTC meetings were held to discuss/update scoring procedures.

Physical challenges included time difference between sites, internet connectivity, language barriers (i.e., varying English dialects) cultural considerations (e.g., some test/task directions were changed based on RAs knowledge of more appropriate wording). Test administration challenges included cultural factors (i.e., allowing for continuation of some tasks beyond time limits for rapport) and RA comfort level with administration of some tasks (e.g., trail making test). Scoring challenges included RAs tendency to score too strictly or leniently and confusion regarding specific scoring criteria. At an initial VTC meeting, MS modeled test administration. Then RAs practiced the tests together. To reduce challenges including time difference, connectivity problems, language barriers, and comfort with testing/scoring, VTC training sessions were scheduled individually between MS and each RA. During these sessions, the RA 'tested’ MS and received immediate feedback. Most sessions lasted approximately 90 minutes with one RA requiring a second session (i.e., sessions were tailored for individuals to obtain level of testing comfortability and competency). After each RA was 'cleared’ by MS to start testing, RAs began testing and scoring. Following MS’s review of several scored protocols, meetings took place in groups in order to improve scoring skills and increase consistency between RAs. Given the continued high degree in scoring variability, a third RA was hired with one of his main responsibilities being to double score all protocols.

Findings highlight important challenges and considerations for remotely training study personnel to administer neuropsychological measures (i.e., RAs in India and neuropsychologists in the USA). Important steps to reduce identified barriers included individualized training sessions, specific training in scoring, and open/ongoing communication channels.