Seeing, thinking and acting against Malaria—A new approach to health worker training in rural Gambia

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  Seeing, thinking and acting against Malaria—A new approach to health worker training in rural Gambia
  this module as a generic planning tool for allied health workers and other extensionworkers at community level will be undertaken. KEYWORDS  Community health nurses, computer based training developing contexts,health worker education and training. Context Malaria is endemic in The Gambia; it is a major public health issue whichaffects mostly children under five years (WHO-AFRO, 2000). The disease isalso responsible for loss of productivity among the adult population, school andworkplace absenteeism and increased household expenditure on health. As amatter of urgency, the Department of State for Health has undertaken toreduce the burden of this disease through a number of strategies, includinghealth worker training (Department of State for Health and SocialWelfare, 2004).In 2001, The Centre for Innovation Against Malaria (CIAM), in Banjul, TheGambia, was established through funding from The Gates Malaria Partnership.In 2003, a proposal for funding of the Seeing Thinking and Acting AgainstMalaria Program was approved. The goal of this program is to empowercommunities in three divisions of the country to address malaria needs. Thiswill be achieved by strengthening the participatory planning skills of CHNs inthese divisions. A six week in-service training course was developed forthis purpose.CHNs form the front line of primary health care work in the Gambian publichealth system. They undertake two years training at the Community HealthNursing School and are then posted to village health circuits and healthfacilities across six divisions. The role of CHNs is essentially health promotion,although they also undertake basic clinical duties and supervise traditionalbirth attendants and village health workers. They are involved in diseasereporting, research and intervention measures. This diverse role means thatCHNs are often overloaded in an already overstretched health service.There is currently no structured comprehensive in-service training programfor CHNs apart from one-off workshops, usually provided by non-governmentorganizations. Prior to the CIAM program, computers were not part of CHNtraining and were not available at the School. Computers can be found atdivisional health offices and are mainly used for data entry, report writing andemail. Access to information and communication technology (ICT) can provideCHNs with opportunities to enhance their professional practice and theirlearning.There is an urgent need to realize the benefits of ICT for health workertraining in Africa. Computer resources are not generally accessed by ruralhealth workers (Wellcome Trust, 2001). Internet users in the African healthsector are estimated at less than 0.1% of the total user population on 388  A. Dawson & B. M. Joof   the continent. They are primarily located in urban centres, leaving rural-basedhealth workers who serve over 75% of Africa’s population without anymeaningful access (Bukachi, 2004). The Gambian situation is no different.Studies have shown that CBT can be equally effective as and potentially morecost-effective than traditional health worker training (Knebel, 2000; Tavrow et al.,  2002; Vivekananda-Schmidt, Hassell, & McLean, 2004). A survey amonghealth workers in East Africa identified a need for access to basic trainingmaterial (especially for rural health workers), and access to ICT. They alsoidentified a need for access to information with relevant local content andlanguage (Ntiro & Mrema, 2003). Issue Project  A six week in-service training course was developed by CIAM and guided by areference group and key stakeholders. For logistical reasons, it was decided thatthe curriculum be piloted with 17 second year, pre-service CHNs. Interviewswere undertaken to determine the learning preferences of these CHNs. Ethicalclearance for these interviews was provided by the joint Gambian Governmentand Medical Research Council Ethics committee.The structure of the training course involved a two-week class-based periodfacilitated by three teachers at the CHN School, followed by a four weekcommunity-based attachment, under the supervision of five senior CHN tutors.In class, students focused on improving their knowledge of the socio-economicand epidemiological burden of malaria, the national malaria control strategiesand developing skills in situational analysis and planning. In the field, studentswere required to demonstrate their commitment to the participatory planningprocess and ability to network.The decision to incorporate a CBT course was based on pedagogical reasons,as well as identified student need. In interviews prior to the training course,most students indicated that they would like to have computers in theirprogram. Some felt that computers would assist them to improve theirknowledge, stating that they can be used to write up notes from class discussion,stored and then printed for revision. Computers were also seen as a tool formaking more efficient use of time. Computers, as one student put it, ‘‘willremove the time we spend in classes’’. One student referred to the possibilitiesthat computers allowed for flexible learning and several indicated that thecomputer was an essential tool on a par with their mobile phones, motor bikesand note books in the field.This package aims to use the features of ICT to enhance and supportlearning, as well as build IT skills and confidence. It would also enable thecourse content to be presented and reinforced in a novel way which isimportant for retention and motivation. Throughout the package, learners are Health worker training in rural Gambia  389  engaged in various activities that are part of the action planning cycle. A largenumber of resources are available including: key malaria policy documents,information on malaria epidemiology, treatment and diagnosis and vectorbiology. The graphical interface was developed using macromedia and acomputer lab was established with 11 networked PCs and a printer at theCHN School. The CD can be obtained from: (Accessed 10 September 2005).TheCDROMformat was selected for portability.It wasanticipated that CHNscould continue to use the CD after the course for reference, using the divisionalhealth facility computer without being reliant on poor internet access. A CDformat can also be copied and easily distributed. The package was designed socontent could be modified and the instructional sequencing changed.An advantage of computer-based learning is the ability to presentinformation in visual and textual formats, as well as provide learners with thechoice of a highly structured, or an all-inclusive learning environment.Accommodating the instructional preferences of learners has been shown tohave positive effects (Boles & Pillay, 1999). Research has demonstrated thatstudents who experience teaching strategies that match their learning processesachieve better test results (Pask, 1975). Specifically, the matching of the modeof presentation and the instructional material can improve learner performancein terms of faster and more accurate completion of tasks (Riding & Douglas,1993; Riding & Sadler-Smith, 1992). Motivational issues may also be importantin the sense that a preference for a particular method or medium may positivelyinfluence the learner’s motivation. Sadler-Smith and Riding present theargument, that it may be useful to accommodate learners’ preferences in orderto address motivational issues, as well as learner performance (Sadler-Smith &Riding, 1999).The CBT package was designed in order to incorporate the findingsfrom this research. The content and instruction is presented according to thewholist-analytic and the verbal-imagery style dimensions (Riding & Cheema,1991). A short exercise at the beginning of the package helps students toselect one of the four routes through the instruction. The wholist routeallows students to navigate through the CD in any order; analysts mustproceed in a logical predetermined way. In the imager route, the baobabtree appears as a metaphor for participatory planning, whereas the verbalizers’screens are highly text based. The activities are also rendered in differentways. Crosswords and questions based on the scripts of village meetingsappear in the verbalizer route, whereas drag and drop pictures activities andquestions based on drawings of people with speech bubbles are presented in theimager route.  Analysis The CBT package was discussed at the one-week pre-course training work-shop for teachers, supervisors and divisional health team members. Most saw 390  A. Dawson & B. M. Joof   computer training as valuable, but many raised the issue of access in the field.Some felt that CHNs should have access to the computers at every divisionalhealth facility; this, they said, would assist with planning and reporting tasks.Others felt that CHNs should not have access to these computers, arguing that,if these machines were used for more than just data entry by clerks, informationmaybe lost and systems corrupted. A debate rose concerning the capacity of CHNs to use computers and whether this was actually part of their designatedrole. As a result, some saw computer training as counter productive. However,several participants felt that access was available at schools, internet cafes andNGOs. They said that IT skills were useful and CHNs, like all healthprofessionals, have to be ‘‘resourceful in resource poor settings’’. One sug-gestion was that information literacy should be assessed in the same way asEnglish proficiency and basic levels should be set for entry into the CHNpre-service course. This would enable CHNs to develop high-level skills.In the interviews most student CHNs reported being nervous at the start but‘‘gradually got used to it’’. All participants indicated that they were pleased todevelop computer skills and would feel confident to use a computer at thedivisional health office, or go to an internet cafe´. The content was regarded asrelevant to their course, particularly as they were all about to go on fieldplacements in the community. Several students commented on the useful andimmediate feedback the package provided. ‘‘The good thing for me was seeingthe pictures and finding out the answers’’.One respondent noted that ‘‘the screens were sequenced, everything wasprogrammed’’. Another student said that ‘‘you move step by step, from oneplace to another...It will direct you through’’. There was some confusion overthe multiple response questions. One student reported never having seenthis type of question before. Participants also had difficulty understandingsome words.The package, according to one student, ‘‘is a very quick learning process’’. Aswell as learning faster, he also referred to the time it takes to copy everythingfrom the blackboard as compared to the ease of reading something on thescreen and printing it out quickly. Another stated that it was easy becauseeverything was already on the CD. She did not have to ask others for notes orclarification. This independent approach was mentioned by many participants.They also liked the self-contained nature of the package. Changes were madeto the design and content of the package based on the feedback received fromthe CHN students. Extra instructions were provided for the multiple responsequestions and the font changed. Difficult words were removed or simplified.The links to PDFs were improved so they loaded more quickly. In the future, aglossary may be useful.The IT officer and training coordinator indicated that the CHNs enjoyed thecomputer sessions and were highly motivated. Students quickly learnt how tonavigate with the mouse and how to execute commands such as opening PDFs,selecting answers, and dragging and dropping boxes. The average time taken to Health worker training in rural Gambia  391
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