This study aimed to evaluate the effectiveness of training CPD training supplemented by onsite mentorship program on the perceived importance and performance in specific areas of RMNH service provision as identified using a TNA tool. The purpose was to offer insights that could inform the design of effective trainings for improving RMNH service delivery in low resource settings.
This study demonstrated a statistically significant positive changes among RMNH healthcare workers following the intervention (training and mentoring).There was a significant improvement in perceived importance and performance in provision of RMNH services, leadership skills, and some research skills. In addition, some items were not statistically significant in terms of perceived importance (e.g., “Providing education and counselling around voluntary counselling and testing for HIV/AIDS,” “Competently managing severe intra- and postpartum hemorrhage,” and “Accessing research resources and influencing evidence-based service provision”) but showed a significant change in performance. Despite this few items, overall, the findings indicate that the training and mentorship skills are of critical important in improving healthcare workers’ performance in RNMH. These findings mirror the current scholarly discussion on RMNH. Research evidence continue to show that healthcare providers improved their performance in obstetric care, including conducting surgical procedures, when they received the correct training and support (Ellard et al., 2014; Wilhelm, Mothes, Chiwewe, Mwatibu, & Kahler, 2012; Wilson et al., 2011). Low- and middle-income countries, particularly Sub-Saharan African countries, are facing a crisis in available human resources for health, including insufficient providers of RMNH services. The literature suggests that evidence-based deployment and training policies have potential to improve service provision in low-resource settings, including healthcare settings in rural Africa (Murphy et al., 2014). Moreover, a previous study indicated that combined exposure to certain procedures in reproductive health has a cumulative positive impact on intention to provide such services in the future (Romero, Maldonado, Fuentes, & Prine, 2015). Therefore, the combined training approach (reproductive and newborn care, leadership, and research skills) implemented in this study has been confirmed to be effective for improving perceived importance and performance in RMNH training.
Good leadership skills are essential for optimal RMNH team performance (Block, Dehlendorf, Biggs, McNeil, & Goodman, 2017; Sibande, 2013). In this study, health system management and leadership skills were integrated in each of the RMNH training courses. The study revealed a significant positive change in perceived importance of and performance in leadership skills, including organizing time effectively, coping with change in health service delivery, working as a team member, assuming a leadership role, developing leadership skills, mentoring and guiding other staff, and supervision and management of community health workers. These findings are similar to those reported in previous studies. For instance, Block et al. (2017) reported that additional procedural training accompanied by mentorship of leadership skills was the most critical component of a program on successful provision of reproductive health services. Studies further indicate that Leadership competencies such as demonstrating appreciation for team members and creating connections between colleagues have been found to improve morale and increase retention, innovation, and productivity, and also have potential to prevent burnout (Hackworth, Steel, Cooksey, DePalma, & Kahn, 2018; Shanafelt & Noseworthy, 2017). Another study in (country) suggested that transformative learning including interdisciplinary leadership competencies such as self-awareness, vision, self-regulation, motivation, decisiveness, integrity, interpersonal communication skills, strategic planning, team building, innovation, and being an effective change agent are effective for an interdisciplinary team of healthcare providers (Negandhi et al., 2015). The present study provided training on general health system management, and further studies may be needed to explore the specific leadership skills required for RMNH in low-income settings.
The research capacity of health personnel, financial resources, positive reward systems, and collaborative relationships have been reported to be fundamental for improving RMNH services (Matus, 2018). However, in low- and middle income countries such as Tanzania, most available funds, expertise, and other resources come from the North-South collaboration, and little attention is directed to research activities (Van der Veken, 2017). In the present study, although there were some statistically significant positive changes in research capacity post-test (e.g., “Accessing research resources and actively influencing evidence-based service provision”), there were no significant changes in perceived importance and a deficit remained in capacity to analyze facility data to inform local service delivery and identifying locally-relevant needs. Therefore, strengthening research capacity in low- and middle-income countries has been reported to be a powerful, cost effective, and sustainable way of advancing health, healthcare, and development (Kabra et al., 2017). Strengthening research capacity may enable healthcare providers to undertake research based on their local needs and priorities that can advance RMNH services and related leadership skills in low- and middle-income countries. Innovative interventions for changing attitudes and building research capacity in research management, proposal writing for grants, and report writing may provide positive changes in perceived importance and performance in research.
The present study provides evidence of positive changes among healthcare workers in terms of the perceived importance of and performance in identified and prioritized areas in RMNH, leadership, and research capacity. This intervention (training program) was unique because it covered the range of knowledge and skills in RMNH and was supplemented by mentorship program in the real-life clinical setting. Mentorship interventions have been reported to have a statistically significant positive impact on competencies among healthcare providers (Creanga et al., 2020). The CPD courses and mentorship program were effective and may be less expensive than other training options because they used local trainers and mentors, which suggested this approach may be sustainable. However, cost analysis may be needed to substantiate the cost of the employed approach.
The Current study have some strength worth mentioning. This study used a combined approach of job and onsite clinical mentorship. Studies have indicated that many trainees lose their skills soon after training therefore the combine approach used in this study ensures retention of knowledge and skills. Therefore, there is a need for continuous use of low dose high frequency training model (Cavicchiolo, 2018). This study is without limitations. At the time the endline survey was conducted, there were varying durations since the CPD courses (6 months to 3 years). Therefore, the observed differences between baseline and endline scores may partly result from changes in the learning climate (e.g., training from other partners) and accumulation of experience through clinical practice over this period. However, the approach used in this study was deemed suitable as it was not considered meaningful to use an artificial environment isolating healthcare workers to study the effectiveness of a training intervention. Second, the baseline was conducted through the TNA questionnaire that may have highlighted existing training needs in an individual participant than the work related perceived performance. Therefore, the healthcare workers may have focused on improving their performance on the identified gaps. Third, though the health facilities were selected randomly, participants were recruited using convenience sampling. This means the findings may not be generalizable to all healthcare providers in Tanzania. Fourth, there was no comparison group, meaning it was difficult to determine whether the observed changes were due to time or the effect of the training program. However, selection of a comparison group was not feasible because implementation of the training program was regional across all health facilities. Moreover, a group follow up was based on the same health facility that might be not the same with the paired groups. Therefore, we treated the baseline and endline survey groups as independent groups and we opted independent samples t-test to test the effectiveness instead of paired t-test.