Abstract
Background: Poor public health indicators in Tanzania have led to the upgrading of nursing and clinical personnel who currently have just core training. Clinical officers (COs) have 3 years training in basic and applied medicine and are responsible for healthcare of large and dispersed rural populations.
Aims: UNESCO-Wales has funded colleagues in Wales (UK) to assist the upgrade of COs. An inquiry into their learning needs and the Tanzanian context has produced a framework for design of a module for COs on sexually transmissible infections and HIV & AIDS by distance learning.
Methods: Face-to-face discussions were held with the Ministry of Health, healthcare workers, educators and administrators in Tanzania; a review of training documents was carried out; and a follow-up questionnaire issued to COs.
Results: The discussions and review highlighted teacher-centred approaches, and management, infrastructure and resources obstacles to curriculum change. Principal learning needs of COs around STIs were: counselling, syndromic management, drugs management, laboratory diagnosis, health education, resources, staffing and service morale.
Conclusions: Placing learning needs in context in dialogue with Tanzanian colleagues was an advance on simple transfer of educational technologies and expertise. The inquiry resulted in a draft study guide and resources pack that were positively reviewed by Tanzanian tutors. Management and resources issues raised problems of sustainability in the module implementation.
Introduction
In 2006 a Wales team obtained sponsorship from a UNESCO committee in Wales (UK) to assist in the reform of clinical officer (CO) training in Tanzania. The project, planned in consultation with colleagues at the Centre for Distance Education (CDE) in Morogoro, was to develop a distance learning module to upgrade the COs’ professional knowledge and skills in combating sexually transmissible infections (STIs), HIV and AIDS. The UNESCO committee agreed to support in 2007–2008: an information-gathering visit to Tanzania; development, piloting and evaluation of the module; and a further visit to induct and develop distance tutors in Tanzania.
This article reports on the inquiry phase of the project in which the learning needs of COs around STIs were clarified and placed in the context of healthcare, education and policy developments in Tanzania. The inquiry provided framework criteria for the design and development of a study guide and resources pack on syndromic management and counselling of patients with STIs. In March 2008, the learning materials were presented in draft to distance tutors and were reviewed positively by them.
Aims of the UNESCO project
An education project on STIs and HIV & AIDS in Tanzania would serve the purposes of a number of key agencies and stakeholders. The reduction of HIV & AIDS in sub-Saharan Africa is an international priority, currently promoted as a Millennium Development Goal (United Nations Citation2007). According to a recent estimate (UNAIDS Citation2006), 1,400,000 Tanzanians have been diagnosed HIV positive, including 6.5% of adults aged 15–49. An integrated approach is needed to address this public health crisis. Any efforts to control HIV & AIDS must be based in the clinical understanding that its transmission is intimately linked to that of other STIs such as syphilis and herpes (Adler Citation2004). HIV & AIDS has caused ubiquitous damage, not least to the education, economies, social welfare and security of societies worst affected by it. Thus, the fight against HIV & AIDS requires inter-sectoral collaboration. UNESCO is committed to such collaboration in improving the continuing professional development of healthcare staff (Ndege Citation2005). A project combining distance learning and curriculum expertise with microbiological expertise and addressing a key public health priority would carry mutual benefits for Tanzania and Wales.
The UNESCO project coincides with an important period of health sector reform in Tanzania (Tanzanian Ministry of Health Citation2003). Since 1960s, owing to an insufficient number of fully qualified medical, nursing and allied health professionals, Tanzania has relied on a service underpinned by staff who have had just core training. Among this number, COs receive 3 years training in basic and applied medicine and provide rural healthcare services to large and dispersed populations. Continuing decline of key public health indicators has led Tanzania to propose the upgrading of a range of clinical personnel. The Tanzanian government sees continuing professional development (CPD) by distance learning as essential if clinicians in remote rural regions are to contribute fully to prevention and control of STIs.
The Wales team's aim is to build on the earlier study of Myemba (Citation2005) and on the longstanding support and training provided to COs by the CDE. Continuing dialogue of Wales partners with CDE and the Ministry of Health and Social Welfare (MOHSW) is seen as crucial in ensuring responsiveness and sustainability of the STI project in the Tanzanian context. Sensitivity to context initially will be advanced by localizing the STI module in Morogoro district, though ultimately dissemination across Tanzania is intended.
In summary, the STI module to upgrade the COs aims to extend their diploma training in basic applied medicine and elevate them to the level of Assistant Medical Officer (AMO). It will thereby assist them in gaining a wider knowledge base in healthcare, an advanced diploma and licensed practitioner status.
Familiarization with the Tanzanian context
At the proposal stage, colleagues at the CDE in Morogoro had stressed the importance of visiting Tanzania to understand and place the learning needs of clinical officers in context. In March 2007, the Wales team travelled to Tanzania to consult with the MOHSW, healthcare workers, teachers and administrators. Discussions in Dar-es-Salaam with MOHSW officials and national distance education co-ordinators gave them an overview of healthcare and education in Tanzania and of ongoing healthcare reforms, now extending to the CO grade.
At the CDE, the Wales partners informally gathered COs’ views on their training needs, the proposal to upgrade to AMO and the UNESCO project. The same issues were discussed at the Tanzanian Training Centre of International Health in Ifakara with the Director, lecturing staff and COs in their first year of upgrading to AMO (AMO trainees). The latter were particularly illuminating in their comments on the face-to-face course in operation at Ifakara. Clinical training was conducted there on the same site as a malaria research centre and St Francis Hospital (providing clinical placements for trainees). The Ifakara experience was vital in acclimatizing the Wales partners to rural remoteness in Tanzania and conditions in the pilot district.
Key social and educational factors in the Tanzanian context emerged from these discussions. With few exceptions, lecturers, AMO trainees and COs were seemed wedded to traditional teaching methods. Lack of experience as independent learners has created difficulties in engaging with distance learning (Bhalalusesa Citation2006). Moreover, there were occasional signs of resignation to the status quo, understandable in a healthcare system that was operating under major constraints, including a recent 22% cut in funding. First-hand experience of transport and communications in Tanzania stimulated deliberation on modes and formats of distance learning to be adopted in the STI module. Selection of learning technologies and educational media would need to be sensitive to learners’ socio-economic status and geographic location, resulting in differential access to electronic media, telecommunications and postal services. More positively, there was a cadre of around 50 clinical tutors in the district who would be able to support learners on the STI module, following appropriate development (Bhalalusesa Citation2006). Project management expertise would be necessary, however, to ensure completion of the upgrading curriculum within available levels of staffing and resources. The long-term success of the STI project and the upgrading curriculum would require management and resources issues to be tackled.
Commenting on learning needs, some COs at Morogoro voiced frustration with their current levels of clinical responsibility. While they could recognize clinical emergencies such as an ectopic pregnancy or strangulated hernia, they had not been trained to perform surgery on them. In a parallel discussion at Ifakara, AMO trainees perceived mismatches between their learning needs and their face-to-face, upgrading course. Repetition and gaps in course content, the balance between curative and preventative approaches, structuring and sequencing of content and the long case assessment were the main issues. As part of their preparation for the STI module, the Wales team proceeded to conduct a detailed review of study guides and handbooks from COs’ existing training (Tanzanian Ministry of Health Citation2005) and to find out more about the course being run at Ifakara.
In their feedback on the Wales team's visit and subsequent report, the Tanzanian government perceived the pilot module as coherent with their strategy to develop healthcare staff by means of distance learning and thereby control STIs, and HIV & AIDS. However, the Wales team noted that previous investment in education and healthcare projects may have only had a temporary impact on the declining health status of Tanzania (and HIV & AIDS, in particular). Such impressions reinforced their commitment to locate COs’ learning needs in context as the basis for sustainable change. Continuing dialogue with project partners and stakeholders would deepen their insights into conditions in Tanzania and help them link the UNESCO project with healthcare and education in Wales. Since trainee AMOs and COs had requested the opportunity to add to comments offered face to face, it was decided to offer them a follow-up questionnaire. Learners’ perceptions of their current levels of knowledge and outstanding learning needs, combined with previous information gathering and reviews of course documentation, would ensure appropriateness in the STI module design.
The learning needs questionnaire
An uncomplicated format was adapted for the needs questionnaire to obviate confounding cultural and linguistic factors in respondents. Adapting a method to generate participants’ priorities for refinement by discussion (Christian & Anderson 2007), respondents were asked:
to identify in order of priority up to 10 difficulties they face when managing STIs and HIV & AIDS;
to suggest for each difficulty what further learning would help them deal with it and improve patient care.
A form with two columns, each with 10 response boxes, was provided for free text descriptions of each difficulty and its corresponding learning need. Respondents could also offer free text comments on any aspect of their learning needs in relation to their existing training.
The questionnaire was communicated by email to 60 trainee AMOs at Ifakara, and by email and post to 20 COs in the Morogoro District who were intending to upgrade to AMO. Completed questionnaires were received from 27 trainee AMOs (45%) and 12 COs (60%). These samples were opportunistic, capitalizing on the interest expressed by these groups during the fact-finding visit. As response rates were not high, it was possible to process the free text comments manually.
Responses from each of the two groups were clustered under clearly distinct categories and presented as a set of 10 tables, with one table aggregating and ordering each priority difficulty/learning need of each group. For illustrative purposes, the tables for Priorities 1 and 2 of both the trainee AMOs and the COs are shown. Clusters of difficulties and related learning needs in Tables and highlight, for example, AMO trainees’ emphasis on counselling and health education. Similar delineation of clusters occurs in Tables and , displaying the COs’ stress on clinical management of STIs and HIV & AIDS. The results and discussion in the following text takes into account of the further eight tables of each group that have not been replicated here.
Table 1. AMO trainees’ learning needs (Priority 1) (n = 27)
Table 2. AMO trainees’ learning needs (Priority 2) (n = 27)
Table 3. COs’ learning needs (Priority 1) (n=12)
Table 4. COs’ learning needs (Priority 2) (n = 12)
Results
In Tables and , AMO trainees showed a predominant bias towards counselling and health education in their training needs, though they shared with COs an interest to upgrade in STI drugs therapies, especially antiretrovirals (ARVs) for HIV & AIDS. The Priority 3 and 4 responses highlight drug regimes yet again, but also laboratory diagnosis, coping with staffing shortages and counselling patients. This wider perspective on sexual health was sustained in their strong emphasis on health education and community sensitization in Priority 5–10 responses. Indeed, individual trainees presented deep-rooted issues such as gender inequality in sexual matters and poverty as priority learning needs. Human resources problems, mainly shortages, low staff morale and lack of professional development figure prominently in Priorities 7–10 of this group.
COs’ responses in Tables and , exhibit a greater clinical management emphasis in their learning needs, as compared with trainee AMOs. This bias was reinforced in their Priority 3 and 4 statements of such needs as learning more on drug regimes and on how to detect and manage opportunistic infections. However, 58% of COs’ Priority 3 and 4 responses identified counselling in STIs and HIV & AIDS as a difficult area. This balance among the main categories was largely replicated in Priority 5–10 listings of this group. Interestingly, one CO mentioned a need for ‘… data management of people treated, cured, dying at home with no treatment at all’ (as Priority 10).
Discussion
Overall, there is considerable commonality across the 10 priority difficulties and associated learning needs of COs and AMO trainees, albeit with different degrees of emphasis. Categories were assigned to significant clusters of learning needs: counselling, syndromic management of STIs, drugs management, laboratory diagnosis, health education, resources, staffing and service morale. Training in counselling was seen as necessary to combat patient attitudes and behaviours that could be damaging efforts to control STIs and HIV & AIDS. Inadequacies in drugs and knowledge of drug therapies presented major obstacles to COs in treating STI patients. Respondents felt that drug problems could be partially alleviated by training them in ordering systems and materials management skills. How to make an accurate STI diagnosis was of equal concern, and for the most part was traced to a lack of laboratory skills, personnel and facilities. In some cases, the cause was seen to be a lack of basic training in syndromic management.
As befits their public health mission, many respondents highlighted the need for health education to counteract ignorance of STIs in the community. Specifically, they wanted to understand and be able to tackle myths surrounding HIV & AIDS, cultural attitudes that reinforce high-risk sexual behaviours and a tendency (possibly greater in males) to avoid treatment. Deeper issues of poverty and rural remoteness were noted as factors discouraging people from participating in healthcare. Inadequacies of staffing, clinical facilities and drugs were categorized as resources issues for both groups. An emerging picture of excessive workload, declining healthcare budgets, absence of administrative support and infrequent opportunities for professional development seemed to resonate with reports of declining morale among clinical personnel.
These powerful messages added detail to what had been gleaned of the COs’ learning needs and the Tanzanian healthcare context during the Wales team's visit. Discussions during the visit in turn provided a framework with which to interpret and apply the questionnaire findings. A set of criteria for the instructional design of the STI module have been derived from the inquiry phase.
Module content
This module will link distance learning via self-instructional text (Lockwood Citation1998) to periods of supervised clinical experience. The text will comprise two study units: syndromic management of STIs and counselling of HIV patients and the community. Language used in the text (English) will be sensitive to linguistic and cultural issues.
Learning and teaching focus
Learning will centre on cases designed to demonstrate specific learning outcomes that COs have to achieve to qualify as AMOs (thereby avoiding repetition of previous training).
Module sequencing and structure
The learning materials will follow a standard format: introduction, learning outcomes, resources, initial reflection on cases, introduction of theory and evidence (critical reading), practical skills development, revisit cases and reflect on new understanding and practice, summary, assessment; work on a professional development plan and self-directed learning (see Appendix).
Learning technologies and educational media
To fit the conditions facing distance learners in the most remote regions, the STI module will employ traditional, paper-based formats. Instructional materials will be largely self-contained and assessed work will be sent to markers by post. The module will be designed to be transferable to online formats, taking account of sound developmental principles (Unwin Citation2005).
Tutor support
Clinical tutors will be trained in approaches to support learners, either face to face or by telephone. Mechanisms to ensure tutor quality will be put in place (Brigley & Kell Citation2007).
Practice experience
The study units will link self-instructional activity to clinically based learning in hospital placements, developing reflective practice and professional dialogue with tutors and peers (Brigley Citation2003).
Assessment
Assessment will be formative and summative, and wherever possible will promote self- and peer assessment (Boud Citation1995). Assessment results will be used to stimulate reflection on individuals’ learning needs.
Continuing professional development
Study units will include practical strategies to promote professional development and collaborations that avoid dependency on attending courses (Gallen & Buckle Citation2001).
These criteria provided the initial basis for the design of a study guide and resources pack for the STI module. These draft materials were taken to Morogoro by the Wales team in March 2008, and were reviewed by a group of distance tutors as part of a 3-day workshop at CDE. Progress towards a relevant and coherent design for the STI module had clearly benefited from the inquiry into COs’ learning needs in context. The tutors broadly accepted the aims, content, format and language of the learning materials, but suggested amendments on some points of detail (see Appendix). They also discussed an assessment strategy for the COs which was to include MCQs, short answer questions and simulated patient cases. The latter were developed and piloted by the tutors at the same meeting, and were one reason for the addition to the STI module of a 2 day face-to-face workshop for teaching and assessment purposes.
Conclusion
It is a mark of the mutual responsiveness and inquiry orientation of the UNESCO project that the inquiry phase was extended into further discussions in which tutors were able to directly influence the design and delivery of the STI module. The Wales team had rejected any assumption that learning technologies, teaching expertise and, indeed, entire curricula can be transferred unproblematically from the developed to the developing world. Continuing dialogue with immediate partners in the STI project and with wider stakeholders helped the team move towards a coherent and sustainable module design, grounded in the COs’ learning needs in context.
It was noteworthy that in both the discussions and questionnaire responses Tanzanian colleagues were unable to divorce their learning needs and CPD from issues of policy and resources. Indeed, in uncovering key aspects of the Tanzanian healthcare training context, the Wales team had become aware of a lack of infrastructure to support training initiatives. This signalled an important area for review and evaluation during the implementation and wider dissemination of the STI module. The fact that COs saw their training in a wider context hinted at further learning needs in their CPD that lay outside the remit of the STI module. Though counselling in the module was interpreted to include community health matters, the COs’ responses clearly highlighted learning needs related to their wider efficacy, for example, as patient advocates, public health champions and influential voices in policy-making. Ultimately, the sustainability and quality of the STI module, the upgrading curriculum and healthcare training in Tanzania may depend on the ability of CO graduates to lead in ameliorating the societal conditions in which curriculum change is implemented.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Additional information
Notes on contributors
Stephen Brigley
Dr STEPHEN BRIGLEY is Senior Lecturer in Medical Education in the School of Postgraduate Medical and Dental Education at Cardiff University.
Ian HoseIn
Dr IAN HOSEIN is Director of Infection Prevention and Control (Cardiff and Vale NHS Trust).
Irnei Myemba
Dr IRNEI MYEMBA completed the MSc in Medical Education at Cardiff University in 2005 and is currently deputy distance education coordinator at the National Centre for Distance Education, Morogoro, Tanzania.
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Appendix: Report of review of STI module study guide by distance tutors
The review was conducted by two groups (6 members in each). One was assigned to Unit 1, the other to Unit 2. Both groups voiced positive comments on the content, format and language of their Unit as follows. They suggested changes affecting both Units: ‘HIV & AIDs’ to replace HIV/AIDS; sections on partner notification to be added. Adaptability to COs’ varying contexts was highlighted as a general issue.
Unit 1–Syndromic approach
The Unit 1 review group reviewed the Unit in four sections. They felt that the module was written in a way that encouraged learning and that the CO would explore around the topic.
They commented that although they felt the document easy to read, clinical officers may have some comprehension issues especially with the concept of Newton's Theory as COs tend not to have studied physics as part of their education.
On ‘definitions’, the group requested an appendix to explain such words as ‘syndrome’, ‘model’ etc.
Tutorial stop points–no answers in body of learning material.
Neonatal conjunctivitis flow chart requested.
Tests described in case studies were not available, e.g. no test for viral culture Herpes Simplex Virus. Test readily available were gram stain, wet prep, rapid chlamydia test, rapid HIV test.
Source materials–full copies of National Tanzanian Guidelines on STI and HIV to be added as an appendix.
Would like to have HIV counselling incorporated into flow charts not in a separate box.
Would like partner notification included in flow charts.
Tutors needs STI knowledge base–crash programme for tutors prior to taking on students.
Collated comments on Unit 1–Syndromic approach
Unit 2–Counselling skills
The Unit 2 review group offered general approval of the learning outcomes, case histories, counselling skills and of the section of source material sampled. The group did not have time to comment on the relevance of counselling theory.
Summary of changes recommended:
First learning outcome to read: ‘Conduct counselling on sexual health matters in a patient-centred framework’.
‘Reflective diary’ to replace reflective journal.
Add further explanation of reflective practice.
Tanzanian National Guidelines on HIV and AIDS to be referenced.
UNISA source to be placed in a footnote.
Wording of question in Case 3 to be simplified.
Comments on cases to be moved to an Annex.
Collated comments on Unit 2–Counselling