Situated in Central America, Honduras is a country of 10 million people. It hosts a mix of traditional culture and modern lifestyles . Based on 2013/2014 statistics, an estimated 4.6% of the Honduran population aged 18-65 were disabled, i.e. 220,800 out of nearly five million people . Particularly, Colon, Atlantida and Yoro, had a disability prevalence of 4.3%, 5.5% and 6.1%, respectively . In addition, extremely disabling sequelae of non-fatal injuries have been documented such as organ removal, loss of limb and paraplegia .
Health System in Honduras
Bermudez-Madriz et al. (2011) described the Honduran health system as a two-tiered system with public and private providers. As part of the public system, the Health Secretariat (Secretaria de Salud) provides directions for the health system as a whole and also provides health services to the population. The Health Secretariat serves the whole population but mainly takes care of those who are unemployed and live in poverty in the urban and rural areas. The private sector provides health services to 5% of the population; those with an income able to pay for health services. It is estimated that 17% of the total population does not have access to any health service at all .
In Honduras, there are several rehabilitation clinics for people with disabilities . The Health Secretariat operates nine rehabilitation clinics located in some public hospitals, and two hospitals for persons with mental or psychosocial impairments . Furthermore, the Honduran Social Security Institute (government body that provides pensions and healthcare coverage) has two rehabilitation centres located in the main cities of San Pedro Sula and Tegucigalpa, which employ qualified technical staff and has modern rehabilitation systems . In addition, the Teleton Foundation (private sector) operates six rehabilitation clinics, none of which are located in northern Honduras . In the rural areas, Honduras has adopted community-based rehabilitation guidelines, as advocated by the World Health Organization and the Pan American Health Organization, as a strategy to improve access to rehabilitation and community integration for persons with disabilities . However, there are many hurdles to implementation of community-based rehabilitation in rural communities due to limited local professional capacity, and administrative and language barriers . Similar to other developing countries, rehabilitation centers and services have sprung up in a haphazard manner and are fully reliant on philanthropic funding sources provided by Honduran citizens and non-governmental organizations [7, 8].
Despite the number of people with disabilities in Honduras, there is only one private university providing a 4.5-year baccalaureate program in rehabilitation (combined physical therapy and occupational therapy degree) which, as yet, has no graduates. The other rehabilitation training programs available in Honduras include: a medical degree in physical medicine and rehabilitation, a technical degree in functional therapy, a baccalaureate degree in phonoaudiology, and a diploma in integrated community rehabilitation. There is no formal system of post professional training opportunities to support rehabilitation workers such as physical therapists in Honduras, nor training beyond the baccalaureate level.
According to the 2013 census , in Colon, a northern province of 271,723 people, there were no (zero) qualified rehabilitation workers: physiotherapists, phonoaudiologist, or functional/physical therapy technicians, or community rehabilitators (Figure 1, Map A). Moreover, the distribution of self-identified rehabilitation workers in Colon was 0.4 per 100,000 people (Figure 1, Map B). The higher density of self-identified rehabilitation workers likely indicates that other professionals and community members such as nurses, primary school teachers, special education teachers, or family members attempted to fill the gap in the rehabilitation workforce in the province.
As the country is now building capacity in rehabilitation, regulatory structures or professional associations for the professions of physical therapy, occupational therapy or phonoaudiology may follow. The slow development of the rehabilitation professions and the small public investment in infrastructure for rehabilitation greatly restrict the care and treatment available for the population in Honduras.
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Figure 1. Distribution of trained rehabilitation workers (Map A) and self-identified rehabilitation occupation index (Map B) by province in Honduras. Source: Prepared by the first author based on the Instituto Nacional de Estadística Honduras (2013)
Since 2016, a grassroots organization initiated by the authors, the Network of Rehabilitation Workers of the Americas, (Red de Rehabilitadores de las Américas in Spanish) has undertaken to support the professional education needs of the rehabilitation workforce in the northern states in Honduras (Colon, Atlantida, Yoro) by developing a north-south collaboration and sponsoring a visiting professor program. Workshop curricula developed by rehabilitation professors from the University of Saskatchewan, Canada and University of Santander, Colombia have been implemented as part of this program. The objective of this study was to evaluate reaction and learning linked to two continuing educational workshops for rehabilitation health workers in northern Honduras, designed by an international group of academics and community engaged rehabilitation workers.
Evaluation of participants’ neurorehabilitation knowledge and learning was based on the Kirkpatrick Model [10, 11] and the Slotnick’s four Stages of Learning Model [12, 13]. The Kirkpatrick framework was originally designed to evaluate human resource development training programs[11, 14]. The Kirkpatrick framework specifies four levels of training evaluation: reaction (components: engagement, relevance, and learner satisfaction); learning (components: acquisition of intended knowledge, skills, attitude, confidence, and commitment); behavior (components: critical behaviors, required drivers, on the job monitoring); and results (the degree to which participants apply what they learned during training).
The Stages of Learning tool utilizes clinical scenarios constructed to address the learning objectives . According to Moore and Slotnick (2006), the learner’s level of engagement with respect to a given learning objective can be classified into one of four Stages of Learning: 1) Scanning – the learner is aware of potential problems that might require their attention; 2) Evaluation – the learner evaluates the potential problems on the basis of applicability to their own situation, the likeliness of finding a solution, whether there are resources available for learning the solution, and whether learning how to solve the problem will benefit practice; 3) Learning – the learner gains skills and knowledge applicable to the problem; 4) Gaining experience – the learner puts what has been learned into action.
The Network of Rehabilitation Workers of the Americas hypothesized that a better understanding of the effects of the workshops can give insights to improve future efforts to build rehabilitation capacity in Honduras.
Aim and Setting
The purpose of this study was to evaluate reaction and learning linked to two workshops delivered through the visiting professor program for rehabilitation workers in two rural cities (Tocoa and Trujillo) in northern Honduras.
A pretest-posttest design was used to evaluate the reactions and learning effects of two workshops. Based on initial feedback, the questionnaires were modified and translated between English and Spanish by bilingual members of the team and approved by the Continuing Education in Rehabilitation Science unit. The language of the workshops and data collection was Spanish. The sociodemographic questionnaire, the MSLQs, and Knowledge Questionnaires were administered to the participants online or in paper format prior to the workshop (Figure 2). The MSLQ was administered immediately after the workshop as a post-test. The MSLQ and the Knowledge Questionnaires were sent to participants one month after the workshops in paper form.
The research proposal was reviewed and exempted by the Behavioral Ethics Board of the University of Saskatchewan in Canada (June 30, 2017). Participants provided written consent to be part of the study.
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Figure 2. Flow of the study. MSLQ=Modified Stage of Learning questionnaire.
The workshop on the topic of ‘adult acquired brain injury/spinal cord injury’ (hereafter adult workshop) was held in Tocoa, Colon. Individuals working in healthcare with an interest in neurological rehabilitation were invited by the host rehabilitation center, Centro de Rehabilitación Integral de Colon (CRICOL), through email to other rehabilitation centers and hospitals in the region. 17 participants attended. The second workshop held in Trujillo, Colon was on the topic of children with impaired neuromotor development (hereafter the pediatric workshop). The pediatric workshop was attended by 15 individuals. All rehabilitation workers of the host center, Little Hands, Big Hearts, a family support organization, and those of CRICOL were invited. Five participants attended both workshops. This was a sample of convenience based on workshop attendance.
The third author (ICGD) together with a physiatrist and a local physiotherapist, conducted the adult (neurorehabilitation) workshop. ICGD is a Colombian physiotherapist, with a Master’s degree in Neurorehabilitation, who has been teaching neurorehabilitation at the Universidad de Santander, Colombia for more than 10 years. The physiatrist has two years of experience in neurorehabilitation in public and private Honduran clinics, and the local physiotherapist has seven years of experience in Honduras. ICGD instructed the pediatric neurorehabilitation workshop independently.
Workshops were planned in partnership with: 1) CRICOL in Tocoa and Little Hands, Big Hearts in Trujillo, 2) School of Rehabilitation Science, University of Saskatchewan, 3) Universidad de Santander, Columbia, and 4) Continuing Education in Rehabilitation Science of the University of Saskatchewan. The themes for the workshops were selected considering the reported needs of the local rehabilitation workers from CRICOL in Tocoa and Little Hands, Big Hearts in Trujillo. After several online meetings between the members of the Network of Rehabilitation Workers of the Americas and local rehabilitation workers, the learning objectives for the workshops and clinical cases were developed. In addition to considering the local context, the workshops were carefully constructed with evidence-based learning objectives written using Bloom’s taxonomy .
The workshop included nine objectives related to neurorehabilitation in adults with acquired brain injury, spinal cord injury, and cerebral vascular accidents (Appendix 1) and was conducted over 2 consecutive days (12 hours duration). It included lectures using PowerPoint, interactive content (class discussion), demonstrations, practical activities among peers, and a case discussion and assessment/treatment demonstrations on an adult patient with cerebral vascular accident.
The pediatric workshop which addressed seven objectives linked to rehabilitation for children with impaired neuromotor development (Appendix 2) was a one-day workshop (7 hours duration). It included lectures using PowerPoint, interactive content (class discussion), demonstrations with a doll, and case discussion and assessment/treatment demonstrations on two pediatric patients with cerebral palsy.
Both Kirkpatrick’s reaction and learning levels were evaluated with the Modified Kirkpatrick Questionnaire; in addition, the Modified Stages of Learning Questionnaires (MSLQ) and the Knowledge Questionnaires evaluated Kirkpatrick’s learning level.
The Modified Kirkpatrick Questionnaire. The Kirkpatrick website , provides several examples of questions that can be used to measure all four levels of training evaluation. A set of 18 questions that measured two of the levels: reaction and learning was used in this study (Appendix 3). The behavior and results levels of the model were not evaluated.
The Modified Stages of Learning Questionnaires (MSLQ). Authors developed and validated the MSLQ questionnaires (Appendix 4A, 4B and 4C). In summary, the MSLQ for the workshop on adult neurorehabilitation had five questions related to the first scenario and three questions related to a second scenario. The MSLQ for the pediatric workshop had one scenario and six questions. The questions used in the MSLQs each represented a specific workshop learning objective (Appendix 4D). There were nine yes-no items for each question. Each item was tagged to one of the Stages of Learning (i.e., evaluation, learning, gaining experience) (Appendix 4E). Using a classification grid based on the pattern of responses, each participant was classified into a unique stage for each question. The first stage of learning, scanning, was determined by exclusion (Appendix 4F).
Knowledge Questionnaires. There were two workshop-specific questionnaires based on the learning objectives for the workshops (See Appendices 1 and 2). The questionnaires included a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) to indicate the learner’s level of agreement with statements directly related to the learning objectives of the workshops. A score from 0 to 4 for each statement was obtained, where 4 was the maximum knowledge score.
Each workshop was analyzed separately. Quantitative data were described using frequencies, medians, and interquartile ranges (IQR). The four Stages of Learning were collapsed into two categories: 1) Scanning/Evaluation; and 2) Learning/Gaining experience. Pre-and-post workshops changes from the Scanning/Evaluation stages to Learning/Gaining experience stages were evaluated using the Exact McNemar test. Pre-to-post workshops changes in the Knowledge Score were evaluated using Sig Test for repeated data. Non-responders were not included in the pre-to-post analyses. A significance level of 0.05 was used. Data analyses were conducted using STATA 13.1 (Stata-Corp, College Station, TX, USA).
 The Network of Rehabilitation Workers of the Americas includes members from University of Saskatchewan, Canada, Universidad de Santander, Colombia, Norway, and rehabilitation workers in Colon, and Atlantida, Honduras.