[MUSIC]. Today, we'll be talking about selecting training methods that will be appropriate for delivering the content that we examined in our previous lecture. One of the important things that we'll look at in the first section is the need to select a variety of different kinds of methods to make our training more interesting for the trainees. There are a variety of different methods available and first it's necessary to realize that different methods are best or more appropriate for providing different kinds of learning experiences. We have different methods for acquiring skills. We have methods that are appropriate for forming attitudes. And methods that are appropriate for enhancing the knowledge of the trainees. There is need to adapt these, methods for training different kinds of health workers. For example, when you have volunteers from the village who are going to be practising first aid or health education. Many of them have low literacy skills or maybe haven't been to school at all. And therefore methods such as lectures where people are expected to take notes, are not really appropriate. We have to think of things in the local culture that people do to communicate and be able to, adapt our methods. There was an example we had of a government sponsored training program for village health workers and they got some money from the federal government to carry out this at one of the local health departments. And because they thought it was important for the village health workers to take notes just as they had done when they were students at the School of Health Technology or School of Nursing. They went ahead and hired some of their nieces and nephews to sit next to the illiterate village health workers to write down things in an exercise book. How that actually helped anybody but the nieces and nephews I'm not sure, but more appropriate training methods would have been things like dramas and songs and stories. Also, it's important to distinguish between the actual training method and the supportive or educational or instructional materials that are used to deliver the methods. we can certainly give a lecture and use a poster, which is a material to support it. We can do a demonstration, and the materials such as live objects, food objects, are supporting the, method of demonstration. Some of you who have, taken the various, social science, core requirements for the MPH degree, may remember the precede framework that helps us understand human behaviour and plan health education and health promotion programs. The precede starts with a diagnosis of the behaviour of concern. And in this case, we're talking about the behaviour of health workers. we would want to look at the trainees and see their behaviours in terms of performing their job roles. So just as if we were looking at the situation in the community of whether a mother gives her child oral re-hydration solution or not, during diarrhoea. We also want, and find out why she does that, we want to do the same with the health workers, why they would, perform tasks such as keeping records or managing their supplies. Some of those factors, if you might recall, include predisposing factors, their attitudes, knowledge, perception, beliefs. All of those things that already come in people, inside people's heads. Other factors that influence people's behaviour are the reinforcing factors. This includes the influence of other people. In this case it may be the clients of the health worker, it may be the co-workers, it may be the supervisors. Reinforcing factors also include rewards that they might get for performing their work correctly or not. And finally the third set of factors that would influence their behaviour, their job performance, would be enabling factors. And these include skills, the availability of equipment to carry out the job and organizational policies that may influence their promotion, their type of treatment that they're supposed to give patients, etcetera. Each of these antecedent factors, each of these factors that influence behaviour imply the need for different kinds of educational or, in our case, instructional methods to help people learn. When we have predisposing factors, the general category of methods that points us toward are communication strategies. In this case, as far as training methods go, would include things like lectures and handouts, and reading assignments. Reinforcing factors, again, the influence of other people. So we would look at social support. Strategies that would reinforce, the social influences on performing a job task. And so this might include training methods such as role play, or group assignments, group tasks. Where people work together with each other and influence each other. Enabling factors we said are skills, equipment, materials, etcetera and we want to use developmental strategies and methods to enhance enabling factors. Examples of these could be demonstration with the return demonstration, where people can practice the skills, having practicals and laboratory experiences during our training programs. In addition to trying to match the methods, with the factors that influence the health workers behaviour, we also have a goal that we mentioned right from the beginning of involving trainees in the learning process. And what we see is that in the chart is that different methods provide greater or lesser, levels of participation or activity in the learning process. If we're simply trying to provide information or knowledge, most of the methods are written or oral instruction, readings and lectures, and the mode of learning, is hearing or reading, this is a less active mode. If we're trying to provide examples to show how tasks are done and what types of attitudes are appropriate for carrying out the work, we can use methods such as demonstrations, pictures, slides, videos, film, drama, case studies and discussion. The mode of learning here is seeing what other people are doing, seeing examples, and discussing, either based on one's experience or based on what one saw. This is getting more active because the trainees are doing something through their discussing. Finally, if we're trying to provide practice or skills through our training programs, we can use such methods as role plays return demonstration, supervised practice, and actually writing up exercises and assignments. In this particular case the mode of learning is actually doing and is quite active so again the implication is that we should match our methods to the type of, content or input that we are aiming at whether its knowledge, whether its attitudes, whether its skills but also we want to provide the trainee as much active participation and active learning and doing as possible. Another way of looking at this issue is on the second chart and we have different levels of role experience outlined here the idea is that training should provide the trainee an opportunity as much as possible to get into, to understand, to internalize new roles, new knowledge, new skills. and what we want to do is as much as possible give the trainee direct experience in these roles. So we have vicarious learning. Learning from the experiences of others. And one can get that through lectures and readings. We have observational learning that occurs when the trainers or the instructors perform demonstrations, take, the trainees on field trips to see what is being done, for example, how a well is constructed in a village. We have reflective, methods, these get the trainees to think, maybe there are some case studies or critical studies, brainstorming, where they think about experiences they had and share those. There are integrative methods that get people to draw on what they've heard during possibly lectures or seen in demonstrations plus merging that with their own experience. So group discussions, films, discussions following films, case studies could be used as integrative. simulated experiences give people an opportunity in a relatively safe environment to carry out and a skill without the chance of them actually making mistakes that would hurt people. Case studies, problem solving case studies, roles plays, and learning games are examples of simulated experience where the trainer sets up a scenario. And, either in the form of a written case study, or verbal cues for role play, or actually assigning roles in learning games. And the trainees carry this out based on their trial and error with each other. come to conclusions in learning about new skills and knowledge. Finally we have direct, experience types of methods, where the trainees actually carry out the tasks that they would hopefully be performing once they return to their place of work. So they can have projects that they work on, if it's a longer type of training program they may have internships, on the job training is clearly a direct form of learning experience. And this is a good example of continuing education, supervised practice, practicals, experiments. So again, what we're looking for is opportunities for the trainee to become actively involved in the learning process and for the trainee to practice and become good at the actual tasks that his or her new job role will require after the training has been completed. We're going to some examples from the African Program for Onchocerciasis Control, or APOC. This program is, focused on the 17 million people in Africa that are living in areas where they are at risk of getting river blindness. Again, the disease is carried by a small black fly from person to person. These flies breed along the river banks, and lay their eggs on the rocks and logs near the river. And people who are farming, and living near these rivers are at risk of getting the disease. Once they become blind, at a relatively early age, they can't farm, they become a burden on society and, it's a major health, economic and social burden to these countries. What is happening now is, that there are programs using a drug called ivermectin to control the disease, doesn't cure people. Once people have been bitten by the fly and, they have been infected with the organism, it grows and becomes an adult worm about 15 centimetres long, they're in bundles under the skin and they continue to produce larva or microfilaria. And these microfilariae migrate to the skin, into the eyes, they cause blindness, they cause serious skin rashes and itching and this is where the morbidity effects come into the disease. But, if people take this drug ivermectin annually, it will reduce the load of microfilariae significantly. And, if they take it for over 15 years, by that time the adult worms would have died and the area would have been free of onchocerciasis. Now, to carry this out, this community directed treatment, community members need to involved, they need to be trained. So volunteer village health workers play an important role. The CDT philosophy, again, is based on a similar philosophy of primary health care, where people have the right and duty to be involved in managing their own village-level health care. As I said before, the program involves annual treatment with this drug, ivermectin. Ivermectin has been supplied free by the manufacturers, they obviously get some sort of a tax write-off, but, again, this, providing something like this free, for millions of people in Africa is no small feat, especially when it has to be carried out for the next 15 years. The issue of the drug supply, again, has been settled because of the company's donation, but again it has to get out to the village. So the villagers must plan for their annual distribution [INAUDIBLE] including how they will get to the health center, where the drug is stored to pick it up. what days the distribution is going to be given on, etcetera. The local health department staff need to go out and organize a series of village meetings, so that the villagers understand their role in carrying out this project where they're helping themselves on an annual basis to prevent the disease from, having serious effects. And, ultimately, the villagers in these meetings will select people known as community directed distributors. The idea of community directed is that the community is directing the distribution process. So, CDDs are very much like volunteer village health workers. Now, just because the village has selected CDDs, it doesn't absolve the villagers of other activities, but the CDDs help lead the activity in the village on an annual basis. Some of the things that need to be done in the village in order to get ready for the community directed distribution of ivermectin include conducting a village census by age group. So the approximate number of tablets can be calculated. Villagers need to be educated about the importance of receiving the treatment annually, based on the census, there needs to be made an estimation of the drugs that are required and somebody from the village or people need to go down to the nearest health center and pick up the supplies from the store. Then also villagers need to be guided to select the distribution mode. Do they want to have the distribution of the drugs taken house to house, do they want to come together at a central point for example in-front of the chief's house or under a central tree? And they also need to decide on the dates, if they're going to do house to house, maybe they can spread it over a couple weeks. If they're doing central distribution, maybe they want to have a special day where they will be doing this. So, again, the idea is that the community needs to carry-out these tasks, need to make these decisions themselves. But these CDDs, community directed distributors once they're selected, can help guide the villagers through this process. Again, other things that have to be done, and particularly, the, responsibilities of these CDDs, is explaining exclusion criteria. Not everybody should take this medicine. People who are seriously sick particularly people who have asthma shouldn't take it. It's not appropriate for children under five years and it's not appropriate for pregnant women. Another task that needs to be done is actually calculating the dose to each individual eligible villager. And this has been simplified, since we can't take bathroom scales or whatever to every single remote village. A height measurement for as a substitution for weight has been developed by WHO, so that you can determine how many tablets a person should receive based on their height. The CDDs need to ensure that people swallow the tablets, there and then right when they're being distributed to know that's it's been effective. They need to record the number of people who have received the treatment. If there are minor side effects which include possibly itching, a little bit of swelling, maybe some dizziness, there needs to be some first aid treatment provided at the village level. And of course, referrel if the side effects are more severe. And after the recording of all this has been done, reports need to be made back to the district health team, including returning any left over tablets. One of our earlier lectures dealt with the issue of recruiting trainees and one of the issues that is involved in selecting CDDs is that, this person should actually reside in the village. Should be somebody who knows the villagers, who is respected by them. Most the villagers would prefer somebody who has a little bit of primary school education, that helps in the record keeping. The important characteristic of course is that these people have to be willing to serve. You can't nominate somebody who doesn't want to do the job. in short, the CDD is likely to be a well known and possibly older local person, with a little formal education. Going through, step by step, in our planning process, we would identify, as we've been doing the different tasks, which include basically the job description of the CDD, talk to the villagers about their beliefs and concerns, gather some information, and use that to formulate objectives for the training. Some examples of this would be prior to distribution, the CDDs will educate villagers on the threat of onchocerciasis and the need to take ivermectin annually. You can look back at our session on smart objectives to see if this one meets the criteria. Clearly we do have a time element in terms of prior to distribution. We have an active verb that's observable and measurable in terms of educating the villagers we can go there and listen to them give talks, etcetera. Another example of a training objective for, the CDDs would be, within two weeks of training, the CDDs will estimate the number of eligible people in their village and the number of tablets that are needed by conducting a village census. They will go to every house in the village. This would not necessarily be a thing they would have to do all alone, the village leaders would probably go with them and then make sure that everybody is accounted for. It's important that not only are people who are eligible are recorded, but everybody, because if somebody is pregnant eventually they'll deliver. If somebody is five years old they'll become six. If somebody is ill at the time of distribution eventually they will get well hopefully. And so we still need a whole census of the village. We also need to ensure that people who are living in the village but maybe of different ethnic group are also counted. So these steps in terms of carrying out the job of the CDD have been drawn from their job description, have been adapted to the local environment and have been specified, hopefully in smart objectives. Now that we have set objectives, in the next section, we will look at learning methods that are appropriate for carrying out the instruction required for these objectives.
