Characteristics of clients interviewed
Findings are based on interviews conducted with 382 respondents. In total 318 were
Frontline health workers and 64 were community level health workers (CHEWs & CHVs). A total of 93 were interviewed
from Kilifi, 97 from Nyeri, 102 from Kakamega and 90 from Nairobi. Table 3 presents
the respondents demographic characteristics from 382 respondents whose data was available
for analysis. The majority (75%) of the respondents were female; 83% were CHV and
68% were frontline health workers. Majority (82%) were in the middle of their career
and aged below 50 years. In terms of professional qualification, 67% of the respondents
were midlevel health workers comprising clinical officers, nurses, laboratory technologists,
pharmacists and nutritionist and community extension health workers (CHEWs). Of those
that reported as CHV, only 2 had nursing experience. Table 3 below shows the characteristics
of the clients interviewed.
Table 3: Characteristics of clients interviewed
Examining role of various actors in the management of NCDs
The study participants were asked to discuss their role in managing NCDs at various
levels. At community level, CHV reported that their role was largely community level
education, facilitating referral, follow up and ensuring clients adhere to the treatment
given as several CHVs pointed out:
“R: My role is to ensure those suffering from any of the disease they get treatment
and they adhere to it because these kinds of diseases you need to be followed up.
We emphasize to them that they should adhere to taking their drugs and the situation
they are in they should accept it. Because something like diabetes you need to keep
on checking yourself regularly” IDI, CHV, site 2
“R: We advise them to seek treatment and we refer them to the hospital for better
management, because for us we do not treat, that is the doctors work and they are
advised on what to do and which treatment they should get” IDI, CHV, site 4
“R: Creating awareness to the community and specifically on health, for you to attain
that you have to take the initiative as a CHV to visit the people in their households
to follow up on their health, one they need shelter that is a place to live in, to
have a means where they are able to take care of their needs maybe a business or to
be employed, they also need to take care of their hygiene, need to have a toilet.
For me as a CHV, the training I have from both AMREF and others before AMREF came,
they used to tell us to insist to people maybe you are pregnant, you are asthmatic,
or you have malaria or maybe they have high blood pressure, you advise them to seek
advice and treatment from the hospital. We used to have referral forms but after some
time we were never supplied with them again, so for now it is up to you as the CHV
to go and visit the client in their households and advise them that the situation
they are in either, diabetic or pregnancy they need to go to the hospital for treatment,
when they decide to come to the facility I make a call and request one of the care
frontline health workers to take care or assist the client I have sent or referred
and we communicate with them” IDI, CHV, site 1
“Okay we go to our households, identify, when you identify you refer because that
is our work I identify, and I refer. I am not a doctor to treat…. So When I refer
the client to our facility she goes there or he goes and receive treatment. When she
comes back to the community now my work is to follow up and if she has a question
which I’m able to answer I can answer if I am not able to answer I refer her back.
I refer the client back because some questions are beyond us: IDI, CHV, site 2.
CHV also implement advocacy, through community platform and includes the youth as
well
“ Okay, like when I was taught eh….You go may be you collect some youths eh…and then
whatever I was taught I will bring to them, to my community. I go to women groups,
to Barraza’s...yeah” CHV 2 site 1
At managerial level, different actors reported that some coordinate the NCDS activities
in the county and mobilise resources to support the programs, health education and
promotion at different levels as well as supervision. “R: My role majorly is on health education promotion whereby we train the community
health work force volunteers and the chiefs and the so as to carry out prevention,
and also do screening so that they identify cases on time and they are able to bring
them for treatment and also the other issue is that we do a lot of training on all
the NCD generally not just diabetes and asthma, but we are doing for all the NCDS”
IDI, NCD-Focal person, Site 2
“What we is advocating for, we are liaising with the pharmacy to ensure the commodities
are available and we want to thank our pharmacy department he is doing good work.
They have really stocked what we wanted. When we came from the training some stocks
were not there, like the inhalers but now they’re there in plenty. Two, on issues
of policy and gate level I can’t say anything but one good thing with HMT in case
we want anything, we propose and then it is implemented” IDI, Mid-level manager, site
3
Reaction to the training and Learning
In accordance with the Kirkpatrick model, we explored the degree to which participants
found the training favourable, engaging and relevant to their jobs. The analysis
shows that there were varied opinions in terms of perceived competence and acquisition
of skills and competencies in the management of these conditions. For instance, only
51% of those trained through Mlearning and 57% of those attending face to face training,
indicated they could correctly identify types of diabetes caused by insulin resistance
and a drop in the amount of insulin produced by pancreas. When comparing CHV and frontline
health workers, 60.7% of the CHV and 61.4% of the frontline health workers correctly
identified the types of diabetes with no differences between the groups.
Depending on the model of training, the process was engaging and allowed learners
flexibility on when they can learn and also provided support to the learning. In
terms of value of training, most study participants across counties noted that the
training regardless of approach was able provide them with skills to influence service
delivery as pointed out below.
“R: It was very good, sometimes I would answer the questions while attending my daily
duties like cooking and sleeping so I miss them a lot. We started from topic one and
now we are in topic four we were even asking them why they have not brought for us
the other topics” IDI, CHV, site 1
“The value of the training? I think I had said earlier maybe I can put it in another
way. This is one of the best trainings that our staff needs to get. So it is one of
the needed training in our facilities. If one has to control NCD, you see when you
staged this in xxxx, you just passed a forest and I have discovered the weather here
changes, it follows the pattern in the whole country but one challenge I’ve noticed
here, when there is pollination. It’s not only pollination from maize, crops…there
is also pollination from the forest in fact you can hear so many people coughing right
now. So the air is pollinated with so many different perfumes so you’ll expect more
patients to come also for asthma. And then the issue of diabetes we made a follow
up to know why there are so many diabetic cases and we have involved the nutritionist.
The problem here is lifestyle of people here. The lifestyle is wanting. You know this
is a sugar cane planting zone, people, their lifestyle is not good. There are so many
alcoholics. There are so many people who are misusing foods. They are not using food
in the right way. They depend so much on ugali here. They eat the junk food. There
is a lot of junk food, people stay several hours without eating like the bodabodas
and then they take soda or they take sugar cane. So at the end of the day they will
develop such related diabetic cases” IDI, Manager, site 3
The participants discussed positive aspects of the training ranging from satisfaction
and improved knowledge in identifying the symptoms for the conditions especially among
CHVs. County level managers also pointed that the training had an impact on CHV in
disease recognition and need for seeking medical care as a coordinator noted:
“ R: In those area where training has been done, because I think you have done your
own assessment … and you have seen like I was discussing with some CHVs and she said
she was happy she was referring more patient, meaning that patient are now realizing
if I have the following signs and symptoms should go for a check-up because it might
be diabetes which before they didn’t know and once they know the effect of the disease
they will actually be feeling that I need to know early to avoid complication so I
think it is very wise” IDI, NCD Coordinator, site 2
Another perceived effect was on community referral linkages with some noting this
has been strengthened while facilities have set up clinic days to focus on the NCDs:
“R: The clients are very happy we have also had more clinics because I remember more
of our rural facilities never used to have clinics especially for diabetes but now
that people are trained they are able to come up with the clinics and especially when
you go to our rural facilities now because of those training they are able to start
clinic days for diabetes and also the community linkage to the facilities have improved
because like I said we link them with support group so you can see in some areas we
have those group that are linked to every facilities we are able to know actually
who is a patient and we are able to follow them right to the community and they are
able to visit one another so that is also, even when it comes to issue of supporting
one another in terms of foot care and the rest, you find that they are able to know
who is who and where they are and even when the client is not coming to the facility
they are able to make a follow up and know why that client has not come during their
clinic day” NCD Focal person, site 1.
Qualitative interviews also show that the training improved CHV ability to communicate
and debunked myths around NCD as indicated below:
“R: Communication skills, how to engage the community either in a group or individually,
the other one is the elearning it has helped us in that, we also used to have patient
within the community and we didn’t know about the symptoms and we didn’t know how
to help them and so we used to live with them yet the person is suffering, so in our
community we used to believe that the person has been bewitched but the skills we
got from AMREF that we visit them and share the information that we got through the
phone it has really helped. And we would like for them to be improved through the
refresher courses because the training that we got has been a long time ago, we are
requesting if you can give us refresher course and if there is anything they can add
on to we will be grateful. But the skills they gave us as per now they have really
helped us” IDI, CHV, site 4
Other evidence of the effect of training was illustrated through a discussion with
CHV who pointed the improved level of knowledge;
“R: On diabetes we used to think when you have a chronic sore you cannot put on shoes
and we also believed if you put on socks the sore will enlarge but through the training
we learnt that such a client need to bathe his feet with warm water and clean well
in between the toes and wipe them with a clean towel and to use socks that can suck
the moisture brought about by heat or sweat and to put on a shoe that is flexible,
not too loose or too tight and can be tied using a shoe lace, we thought such a thing
is not possible for someone who has such a condition, but know we know what to share
with diabetic people. There others who are diabetic and still smokes and drinks alcohol
those are some of things we have share with them that if they continue doing that
it will deteriorate their condition, those are some of the things I learnt’ IDI, CHV, site 1
For CHVS training benefitted the community since most of them were able to take the
knowledge back to the community. Frontline frontline health workers also gained skills
in classification of clients who come in for asthma:
“We agreed…we were trained in a mixture of nurses, doctors and clinical officers,
our major request to all was to make sure the outpatient department is having diabetic,
asthma training clinical officer always on duty so that there is proper diagnosis
of asthma. Once the diagnosis is made there is a classification. They classify whether
this patient is mild, moderate, severe…if it is severe they admit here. Now in the
ward here am trained in asthma management. Now the telling lands in my hands and I
have done OJD to the staff on how even to use nebulizers to use all those things to
make sure” IDI , Front line provider, site 1
While others reported effective referral to higher level facilities when they cannot
manage it due to scarcity of the commodities or structural challenges to maintain
adequate supply chain system:
“ We …we get referrals but we have also trained staff in the health centres on the
case management of asthma .So they Know those cases to refer here, they refer without
wasting time. But also we have stocked commodities in the same facilities related
to proper asthma management and the only issues on diabetes…because many of them are
not having fridges to keep like…eemm…insulin. They are having fridges for keeping
tissues. So but the, in case they identify a diabetic case, they should refer to our
county hospital here” IDI, frontline provider, site 4.
The skills from the training enabled frontline health workers and CHV alike to have
confidence in managing the condition: “The value of training is that it gives you the confidence when you get the chance…err.
Mmhh just as I said first, with such people, approach is very important” IDI, CHV,
site 2
From the provider perspectives, training was able to empower them, and they were appreciative
of the process. Quantitative results show that there were no differences among the
respondents based on the mode of training in terms of the level of knowledge on diabetes
and asthma. There was high level of knowledge regarding symptoms of diabetes and
asthma among respondents trained trough different approaches. Only 48% of those who
received training through face to face reported that post-partum care visit can be
used for diabetes education prevention, compared to 87% of those trained through E-learning.
Overall, the respondents were knowledgeable of symptoms associated with diabetes,
irrespective of the mode of training. These results also indicated that the Learning
aspect i.e. the degree to which participants acquire the intended knowledge, skills,
attitude, confidence and commitment based on their participation in the training was
largely achieved by each model of training with no differences between the groups
as indicated on table 4.
Table 4: Knowledge levels on Diabetes
Table 5 shows that close to 90% of the respondents trained using different approaches
correctly reported that Asthma is not a communicable disease. In addition, majority
of the respondents disagreed with the statement that Asthma predominantly affect female
children, although 20 % of those trained through E-learning and 17% trained through
M-learning agreed with the statement p<0.001. Majority (69%) of those trained through
E-learning agreed with the statement that physical activity can trigger asthmatic
attack in children, compared to 62% trained through face to face and 52% trained through
M-learning. There were differences between groups on those who reported as true that
Asthma is caused by a swelling of the lung with nearly half reporting as positive.
In another instance, 53% of those trained through M-learning noted that exercise and
upper respiratory infections can trigger acute asthma attack compared to 81% and 74%
trained through face to face and E-learning respectively.
Table 5: Knowledge levels on Asthma
Qualitative results also confirm that the training had an effect on how frontline
frontline health workers are managing asthma and the improved community awareness
of the condition: “The training has affected in a positive way not a negative way. One, it has made
the community to be aware that asthma is another challenge that is facing our people.
You know when we are teaching them, we teach them ten percent of the relevant population
is asthmatic. So when we say that, that message echoes with them. You know people
want to hear what is disturbing them. So even as we make them, many of them to attend,
if you visit our outpatient, you will see so many patients. Especially this time of
the bad weather and many of them they are having halfway knowledge about asthma, halfway
knowledge about diabetes. Because it has made the people themselves even to ask more.
There was an MCA who came here asking that his people must be told of asthma he has
heard it being discussed somewhere. So meaning that something is happening in the
community just after this training to make even an MCA to overhear it somewhere and
then ends up coming asking, can you send some people to teach my people” IDI, Mid-level
manger, site 2
Understanding Behavior change and organizational performance
We examined the degree to which participants apply what they learned during training
when they are back on the job and the organizational performance that occur because of the training and the support and accountability package. Secondly,
we also examined required Drivers- processes and systems that reinforce, encourage and reward performance of critical
behaviors on the job.
Post training experience shows that there was a high rate of agreement of all the
post training aspects asked. There were also no differences between the groups in
all aspects examined except those who reported the way they managed asthmatic and
diabetic patients before the training has not changed with low percentages of between
12% and 20% across the groups. Regarding post training experience, the respondents
felt they were well equipped with skills to address childhood asthma or diabetes 85.6
and 94.2% respectively. Nearly 96% also reported they can teach their colleagues what
they learnt as shown in table 6 below.
Table 6: Perception of post training experience
All the study participants reported that they were able to utilise the skills they
acquired given that the NCDs in question were largely neglected;
“R: Of course, yes because as a CHV there is the knowledge we had gotten from other
previous training but still the community still believed it was being caused by witchcraft.
Even asthma they used to believe it is something they have inherited from our ancestors,
so they didn’t even see the need of seeking treatment and they used to take it as
something that is part of their family, so eventually they would die because they
never sought treatment. Through the training and staying with the community, we usually
attend the chief baraza and we request him to give us a few minutes to talk to the
community about the disease and it is something they can seek treatment and be treated
and get cured. IDI, CHV, site 3
There was an observation that the main drivers that worked against the effective reward
of positive behaviours after the training were largely health system factors. Despite
the improvement associated with training, several health system challenges may inhibit
continuity of service delivery for the NCDs. For example, lack of tools to monitor
progress was reported as a barrier to identifying the real burden as was reported
“R: For asthma the biggest challenge is that we don’t have a…reporting tools for asthma
and also with diabetes and hypertension, in fact it is only now that the national
government has developed a tool which I was lucky to see but has not yet also been
launched, but at least now there is going to be a proper recording, so I want to believe
because of lack of proper registers like for asthma, diabetes there many cases which
are not reported but they are being seen” IDI, NCD -coordinator, site 2
It was also observed that the challenge of human resource constraints is affecting
the sector. One respondent reported that: “R: As much as you would like that person to remain there in the clinic and not do
anything else it is almost impossible because of the inadequate workforce” IDI, NCD
coordinator, site 3
“R: Human resources it is something that has been a challenge like for the medical
officer they are few so in one clinic we may get over 70 patients so managing all
those 70 patient at a go with one medical officer sometimes it becomes a challenge,
so most of the time we have been using two officers and may be if we get a clinical
officer, we had a clinical officer who was attached to the clinic but now he went
for further studies so now whoever is off or something we request them to come to
the clinic so that they can help the doctors to see the patients” IDI, front line
provider, site 2
There are also challenges of supply of commodities such as diagnostics and the cost
associated with the drugs and supplies that might negate the efforts made for NCDs
“R: The other challenge we have is the commodities, commodities for NCDS it is a very
big challenge because again I will come back to the programs like the HIV, Malaria,
T.B program we get support from the global funding program so all patients visiting
our clinic for HIV services, they get them free” NCD-Coordinator, site 4
Additionally, the funding challenge and the fact that communities still believe that
once you get the diseases it is like death sentence makes it hard for example to convince
to seek care promptly. The process of referral to the facility for care is also affected
by lack of referral booklets affecting documentation of care. Availability of referral
booklets will facilitate follow up by CHVs. “R: One major challenge is a gap in the referral between the community and the facility,
we cannot say they are not there, we have limited supply of referral booklets that
are given to the CHVs in event they get a person with a condition that is closely
related to asthma and diabetic they can actually refer. But what they do they actually
take verbal or oral referral which sometimes it is not that effective because by the
time the patient comes to the hospital there is no guarantee that she or he has been
taken care of or has been seen by a clinician” IDI, CHV, site 1
Another challenge is lack of space for the NCDs patients while in some facilities,
the infrastructure may not support free movement of clients when they are being treated
as clinicians reported “ like for instance you come and see mothers have the MCH, TB have their TB clinic but
these guys when they come they enrol as general patient at least having one common
group for them it will be easier and having a clinic in all the facility having a
special clinic for them to be attended to. Like for instance we look at xxxx we have
only one facility that has a clinic day, others they just come any other day, sometimes
you come there is only one clinician who is to attend all the patient around and has
to look at you, and this is a patient who cannot withstand long time at the queue,
so most of them prefer to go to the private which is so hard now to trace because
the private facilities are not attached to the CHVS, so it hard to trace them how
far they have gone with the treatment. IDI, Focal person, site 3
At the community level, financial limitations to seek care and means that referred
clients will not be able to access services. CHV demotivation from comments made by
some members who don’t appreciate the role they play in household visits as one pointed
out: “R: One of the challenge that I go through and specifically when doing follow up and
maybe I have gone to visit him after two or three weeks and they tell you that they
think you are idle because you keep on going around visiting people it seems you are
being paid a lot of money or you need to get something meaningful to do, if you are
not being paid you wouldn’t be coming here now and then to keep on telling us to go
to the hospital if we are feeling or if we are having such and such symptoms, to us
CHVs it is a challenge, sometimes what we go through when we are doing our duties
it is very tough and sometimes I feel like giving up or I am tired but I encourage
myself not to give up and pray to God that one day he will remember me and also the
community to change their perspective so that we can be like the other communities
are living. So for me one of the main challenge is being told that you are being paid
yet you know it is a volunteer thing you are doing and the only time you get something
is when we have a seminar or a meeting at that time we are given five hundred and
I have left my business and I have a family that is looking up to me. Sometimes we
want to include in our reports that we want to be paid something maybe one thousand
at the end of the month, but we don’t do that, we just comment and say we are grateful”
IDI, CHV, site 1
Despite the organisational challenges described above, some reported that support
supervision and issuance of supplies are two main ways in which the front-line provider
get support beyond the training. Secondly, in terms of budgeting for NCD, it was reported
that there was increase of allocation of budgets for NCDs and structures which may
facilitate continuity of improving care for NCDs. Finally in terms of support, respondents
discussed the strengthening of outreaches where the health workers are involved to
go out and carry out some of the activities with the support of the facility level
or the county or sub county level as a critical element of support. This helps them
to put that knowledge to practice. Additionally, the mention of a conducive environment
for them so that if its infrastructure then at the hospital level, funds for their
monthly expenditure was noted as a manager noted “ So part of the monies then is geared towards actual lab services, pharmacy. Even
as we buy drugs at the county level the hospitals are able to buy drugs at their hospital
level. The dispensaries get some money, the health centers get some money so there
is a bit of that happening at the level where if you don’t have a blood pressure machine,
the facility does not wait for the county. If you are given ninety thousand in a quarter
then you are able to slot some of that money to buy thermometers, to buy yourself
the BP machines” IDI, Manager, site 3
The discussants were able to identify that the training was useful in ensuring they
can continue providing services to the clients as one CHV noted:
“ R: It will be of help because in my community it is not easy for someone to get
this kind of disease because even if it is my child I know how to protect them from
asthma, so it has helped me and will continue helping me later on.” IDI, CHV, site
2
Frontline health workers on the other hand noted the long term effect of the training
was local management of condition that they were previously referring; “R: Before we used to refer them to XXX for the services or treat them and give them
drugs and advise them on where to get specialized care and because we didn’t have
the knowledge and skills then we would refer them to XXXX clinic just like the one
we want to start here, before it used to be a burden to us because when a client comes
in instead of referring them to XXXX where they have people who are trained like the
MO or CO we have people who are trained and they are able to handle at least we
are happy we know what we are doing” IDI, Facility in charge, site 3
The progressive effect was also described in the context of reducing complications
as some noted; “R: It has decreased because looking at the NCDs, the clients who has been diagnosed
with diabetes and it is because of the management you can see the complications they
have reduced” IDI, NCD coordinator, site 4. While there was less frequent attack among cases of asthma or number of cases reducing
as indicated below: “R: In the last three years after the inception of AMREF the cases are a bit coming
down, from what we are seeing from the hospital side, like the number of cases that
are being reported nowadays, is not as high as it is, maybe one would say the community
are empowered early enough in management so they do not have time to come to the hospital
for checkups, there so many factors that attribute to it. From the look of things
from the hospital point of view is that cases are decreasing” IDI, Focal person, site 4
Continuity was considered through developing newer strategies to manage the condition
both at management and facility level. Streamlining the drugs for the NCD resulted
to increased number of patients coming “ …. but after the training we started stocking from KEMSA, so when they know medicine
is available they come, so I cans say I didn’t have any challenge then because just
a few who were coming …” IDI, Facility in charge, site 1
Use of support groups appear to have resulted to the increased awareness of the conditions
as one seemed to suggest: “ R: Yes, I will say so because right now they have a support group, I won’t mention
the number but I know it is a support group that is almost exceeds a hundred plus
patients who normally come together at least they are able to know this is a condition
that it is not only me who has it, there other people actually living with it, they
normally have a time to come and share experiences and challenges and what they are
doing about it, which is a good step actually” IDI, Focal person, site 2
Finally, the training has enable facilities to plan on how to reach the cases and
integrate them with the existing process and structures as manager reported “R: Yes that is the major thing and people have taken it into their mind and now fully
understand that NCDS is a silent disease that kills, so people have taken keen interest
on it like right now we are talking of situation where we can have integrated outreaches,
where NCDS can be part of the condition to be checked, now when you go for integrated
services, there normally focused on ANC and then the cervical screening, HIV but now
the way the trend is going have been incorporated we can have on the outreaches, when
we have them here patient can be screened for free and it is just the same stripe,
once you take the blood of sample for HIV you can use the same to check for sugars”
IDI, manager, site 1
Perceptions on Innovative Learning Approaches for Building Capacity of Frontline Health
Workers
It appears that there were many aspects of the mode of delivery for all the training
approaches that were well received. Those trained through face to face, e-learning
and m-learning overwhelmingly agreed with the statement that the training was worth
their time (96%) with all the groups having satisfaction rate of over 90%. Very few
(17.5%) agreed that the they felt frustrated with the training process, the eLearning
group having the highest rate (27.8%), compared to face to face group (13%) and m-learning
(17.2%) and blended group at 14%.
Accordingly, the respondents noted that the training achieved its objectives (92.1%).
Compared to other modes of training, 65% of those trained through e learning were
satisfied with the approach used in delivering the training, compared to 90% in face
to face, 89.1% of the Mlearning and blended group; p<0.001. In addition, majority
of the participations agreed that the skills gained are being utilized (94.2%) with
the blended group reporting the highest 96.1%.
Qualitative evidence indicates various participants had varied views on the approaches
to the training. Key informant interviewees were largely happy with the approach used
in building the capacity of health workers to manage and diagnose diabetes and Asthma.
Overall, there was agreement that the use of both the e-learning and M-learning were
the modes of choice due to the ability to reach higher numbers, compared to traditional
form of training which require huge amount of resource to reach a wider coverage.
The two were further found to be convenient especially for busy health workers who
might not have time to attend training workshops, associated with traditional forms
of capacity building through training. Each of the approach used had merits and demerits
as described below.
Some preferred face to face with various reasons. “R: I still face to face for our type of people is the best and the mLearning , I
find it very good especially for the CHVs it is fantastic but the eLearning program
I think it has a problem and so some people are doing it well down there and again
you know with eLearning sometimes someone can be doing it for the sake of finishing
right?” IDI, NCD coordinator, site 2
The reasons for preference of face to face was greater attention and ability to ask
questions when need arise, interaction with other participants and the advantage of
the practicum such as how to use the spirometer, positioning of inhaler especially
for children. Face to face was thus perceived to have a human feel and allows interaction
with the facilitators which can enhance learning, nurturing different experiences
and gaining from the interaction as some respondents noted
: “With the face to face you hear, listen, see and when it comes to practical’s you feel
so all those media something remain.And, you ask if you are not sure, also there is interaction and discussion and you
gain different experiences from different people. Face to face is actually very effective
according to me” IDI, NCD coordinator, site 3.
“……. You know face to face people get attention, you hear it first hand and you can
ask if you are not sure and sometimes there is a practicum session like how to use
the spirometer, if it is an inhaler how it is positioned, how can I support a child
who needs an inhaler, I think seeing a picture and reading it on your own and someone
sharing about it and asking you questions and they answer you and practically you
see they are two different things”. NCD coordinator site 2.
The demerits of face to face training was discussed in the context of costs of hosting
the trainees as well as short time it takes for training which does not give enough
time to digest everything;
“R: That was their view, if I give my view from national training it is so compact
but in a very short time it does not give you time to digest everything but again
personally at my level, I know the training are very expensive at their level they
may not understand, but just training forty people and accommodating them for five
days it cost a lot of money and the resources are scarce so I want to believe that
maybe the revision of curriculum it might be a bit easier to understand within that
short period” IDI, NCD coordinator, site 3.
In addition, it may suffer from the competing tasks at places of work as a provider
noted “R: It is good but now getting all the people at once due to competing task, they are
called for a training and then there is another training going on or taking place
at the same time you find that not all people will be able to attend” IDI, Front line
provider, site 1.
For eLearning, the probability of reaching many people was discussed as major merit.
One of the respondent for instance noted; “I think with eLearning platform you can reach many people in a very short time, you
can reach multiple health workers and you can communicate to them online if it is
something they do not understand that is one advantage of eLearning program, you can
reach so many people at a time”, IDI, manager site 4.
It can also reach multiple health workers. Additionally it was perceived to sift
the committed ones as indicated by the time taken to complete it: “R: You see when it comes to eLearning you know who is committed because they will
take up the module very fast, but those who are not committed some don’t even bother
or they take long and some have not even finished” IDI, NCD focal person, site 2.
Which means that eLearning program requires commitment but can be limited by internet
to complete the module.
Managers on the other hand reported that mleanring and eLearning has advantage to
the lower level cadres. The reach was described in the light of availability of materials
online that can be used by person who never attended the training thus updating them
as well; “… I would prefer e-learning with mentorship attached. I’m saying e-learning because
like Amref is doing some programs on management of pregnancy and whatever. You see
we are already having notes on our computers. We are having computers in every department.
So, everybody is opening, even a nurse who is on night duty can read things like updates
on management of antenatal care and whatever… IDI, Health manager, site 2
The main disadvantages of eLearning and m-learning were related to limited access
to internet or power. This may be pronounced because of the internet for the rural
facilities where shortage of electricity or network coverage may limit access that
may interfere with a smooth process of learning as indicated by the following excerpts;
“…There was that challenge many people were complaining about it, that is internet and
not so many people have internet…” IDI, site 3.
“R: For me I will go with I mLearning because I believe all health care have access
to phones and you can just do it at your own free time compared to what I got from
eLearning (M coughs…) like there was an issue with internet connectivity at one point…”
IDI, Front line provider, site 1
In other instances locations to conduct the self-learning makes the approach difficult
for learner to effectively utilise the approach ; “…I don’t mind, eLearning is good if we have time and maybe offices or somewhere to
sit and do the eLearning” , IDI, Site 4
Another interesting dimension that came out was the need to get support time to time
during learning which makes eLearning model difficult to implement in cases people
need help. This in view of this was seen to require some form of face of face interaction
at one point or another as was mentioned by a facility in charge:
“…You know people cannot, sometimes people need to be led. So we can have somebody like
a focal person on the same who can be going round and telling we are having this on
the computer read, where you are having a challenge, do this. So in other words am
saying, as much as we may advocate for e-learning there must be some element of face
to face…” IDI, Facility in charge, site 4
The mLearning was perceived interesting and easy to especially because one can learn
from anywhere and one can gauge oneself as the learning progress as was pointed that:
“R: One, with the mobile I believe everyone has a mobile phone and you can do it, it
is a mobile phone meaning that I have it wherever I go, so at any given time in a
matatu at home or somewhere I am bored, I can actually go into it and read as opposed
to eLearning that have to find a good place that is connected to internet and then
start reading so that is the good thing with the mobile and in case of anything you
can enquire from the others. Because there was that other group that was formed and
in event there is an area you feel you are not sure of you can clarify to other members
using that platform” IDI, Frontline provider
The other merit was also discussed around mass reach to many people and with the current
trend of use of technology provides an opportunity for people to learn at their own
time;
“It’s very convenient for, particularly for us who are busy, you can easily log in
and go through. So it’s the method that is advisable I think. That’s the direction
we are moving particularly if you want to train a mass of health workers. You don’t
want to affect services going on…”.IDI, Manager, site 4.
The demerits lie in the requirement of an internet enabled phones which sometimes
is assumed to be available yet may not be universal. It was also challenged by utility
of the phones where some could not easily navigate it or when they share a phone with
others it may limit learning.
“R: One that I have seen is that there was some certain types of phones that the responses
were taking too long to download, I don’t know whether it is an issue with the network
or it was an issue with phones, but I don’t know, I am not sure of. And then another
thing with the phone with such a thing that is too detailed, you find it coming in
bits by the time you get to understand the whole concept you actually forgotten what
you have read previously, so if it can be shortened to make it short and clear” IDI,
frontline provider, site 3
“I would prefer e-learning with mentorship attached. I’m saying e-learning because
like Amref is doing some programs on management of pregnancy and whatever. You see
we are already having notes on our computers. We are having computers in every department.
So everybody is opening, even a nurse who is on night duty is able to read what ehh...like
updates on like management of antenatal care and whatever. So if we had those kinds
of notes on our computers and then we must have somebody. You know people cannot,
sometimes people need to be led. So we can have somebody like a focal person on the
same who can be going round and telling we are having this on the computer read, where
you are having a challenge, do this. So in other words am saying, as much as we may
advocate for e-learning there must be some element of face to face. IDI, Mid-level
manager, site 2
Additionally, there may be limitations in terms of language used in the content as
some may require using a language that can be understood more widely in cases of individuals
who may not understand English for example
“…. I would advise that for m-learning to provide content even in Kiswahili because
most of us we had challenges because the content was given in English” IDI, CHV, site
1
This means that there may be cost associated with developing content in more than
one language, which may initially be costly for the approach. Nevertheless, it was
noted that even after going through the course, there was a common thread that there
may be need for refresher training to remind learners of what they have learnt regardless
of the approach used
“…And there was no review…and you know…with human beings, you can forget …that’s is
why you see people go for refresher courses. I thought after finishing the course”
IDI, front line manager, site 3
In a nutshell, table 7 summarises the merits and demerits of the various training
approaches as shown:
Table 7: Merits and demerits of the different training approaches