Q and A: Taking New Skills Home: Regional Training Program Builds HIV/AIDS Capacity in Asia

Although HIV/AIDS has been a deadly threat throughout Asia for more than a decade, key players in health, policy, communication and journalism have not always had access to the information and tools they need to design and manage effective prevention programs or to report knowledgeably on the disease through the mass media. With seroprevalence rates rising throughout the continent, ongoing training is essential to the success and sustainability of efforts to prevent this complex, ever-changing epidemic.

From 1993 to 1996, the AIDS Control and Prevention (AIDSCAP) Project's pioneering Regional AIDS Training and Education (RATE) Program offered such skill-building opportunities to 111 professionals from Thailand, Cambodia, Laos, Nepal, India, Bangladesh, the Philippines, Mongolia, Sri Lanka, Indonesia and the South Pacific islands. Training was organized around four general themes: behavior change communication, sexually transmitted disease (STD) management, policy development in HIV/AIDS prevention (including workshops for journalists) and training of trainers.

To build the capacity of regional institutions to sustain this important training function after AIDSCAP's funding from the U.S. Agency for International Development (USAID) ended, centers of excellence were created at three Thai universities: Dhurakijpundit University's Asia-Pacific Development Communication Center (ADCC) for training and behavior change communication, Mahidol University's Institute for Population and Social Research for policy development and journalism training, and the Women's Studies Center at Chiang Mai University for gender issues.

AIDScaptions asked Dr. Chalintorn Burian, who directed the RATE Program from AIDSCAP's Asia Regional Office in Bangkok, Thailand, to reflect on the program's success and share her thoughts on lessons learned in sustainability and capacity building.

How did the RATE Program begin?

When I joined AIDSCAP in June 1993, USAID's Asia Near East Bureau had just approved funding to develop human resources for AIDS prevention in the field. AIDSCAP conducted an assessment with AIDSCAP resident advisors and other health leaders in Asia to determine the region's training needs.

What were some of the concerns in the design stage of the program?

From the very beginning, we looked at the issue of sustainability. We knew in 1993 that there were only three years of funding left for AIDSCAP, but that it would take longer for our training efforts to have a real effect. This led us to the idea of building the regional center of excellence in training and communication skills development at ADCC, which continues to conduct training workshops created by the AIDSCAP effort, and the two other centers at Mahidol and Chiang Mai universities.

Did you follow a design model?

Actually, this approach in capacity building is unique in the field of AIDS prevention and in public health generally. I got the idea from the private sector, when I worked as the human resource development director for the Petroleum Institute of Thailand. The centers of excellence concept is widespread throughout industry as an effective way to build both individual and institutional skills, and it seemed to us that it would also work well in health training.

In what other ways did your experience in human resource development influence RATE's design and start-up?

It helped me identify three key issues. First, what needs to change? Second, what are the skills, knowledge and attitudes we need to build? And third, can these be taken back and applied in other countries? In many ways, this third question became one of the biggest and most interesting challenges throughout the three years of RATE's existence, as well as a major focus for the evaluation we conducted as AIDSCAP's role ended.

Why was that?

Connecting the right skills, knowledge and attitudes with the people who can best use them is only the first step in training. We worked closely with USAID missions, AIDSCAP country offices and national health agencies to recruit bright and energetic participants from across Asia who weren't just looking for a vacation abroad, who would take responsibility for applying what they learned back home. But in the beginning we sometimes found that even some of our most motivated graduates couldn't fully implement their new skills when they returned and we needed to figure out what to do about it.

What was the problem?

There were many possible reasons. The home agency or supervisor might not be convinced of the need to put resources into HIV prevention, or might not be supportive for other reasons. Some of the techniques that RATE trainers seek to pass on to their peers back home may be conceptually difficult to accept. It could be a working environment problem, a management problem, a funding problem, a problem involving cultural norms, a staffing problem.

Can you give us some examples of these constraints?

One Cambodian respondent to our evaluation questionnaire complained of limited staff to conduct BCC materials development. An Indonesia health reporter told us that her editor said she already "writes too much about AIDS." Others reported resistance from fellow medical personnel to adopting STD syndromic management guidelines.

How did RATE deal with such a broad range of issues?

The solution was always multifaceted and ongoing. First, we had to refine our selection process by working directly with supervisors, making sure that they saw value in this training and intended to fully support their returning graduates. Such collaboration, combined with information from questionnaires filled out by participants before training began, helped us assess the needs of a particular organization so we could tailor the curriculum to those needs. Second, we stayed in touch with our participants long after their initial training experience ended, follow-up that became an excellent source of feedback for us.

How was this follow-up conducted?

It happened both in the field and in subsequent RATE training sessions. Whenever possible, I or other AIDSCAP staff visited graduates at their home agency within the first few months after training to observe them at work and often help them on site. Those visits gave us an opportunity to see how applicable and adaptable the curriculum had been for that individual and how to improve the training experience in the future.

We also invited many participants back to Thailand to continue their training, and by that stage many had a clear idea of what they needed that they didn't get the first time around. We paid lots of attention to that feedback.

Have you made any unexpected discoveries as you do these assessments?

Well, we have discovered a syndrome I call "separation-from-your-mentor" illness that strikes some of our graduates, especially the ones who haven't stayed in touch. Some find that returning to their home environment can overwhelm their training, especially if they're the only ones around who are dealing with new technology or have attained new technical skills. They end up reverting to old ways of looking at and doing things. Follow-up and ongoing support are the best possible cure!

Could you give an example of new perspectives RATE participants gain through skill building?

Here's an important one: understanding the concept of behavior change communication (BCC), as opposed to the more familiar information, education and communication (IEC). Graduating from IEC to BCC by learning about theories of behavior change is a big conceptual leap that really advances their programming skills. In our BCC courses we expose participants to a behavior change framework developed by AIDSCAP over and over again through multiple exercises, using many of AIDSCAP's excellent new BCC handbooks. Mastering these strategies is a very exciting intellectual as well as professional breakthrough.

How was AIDSCAP's recent evaluation of the RATE Program conducted?

Both quantitative and qualitative techniques were used to gather information, primarily through questionnaires sent to RATE alumni, in-depth interviews and follow-up workshops held in each country. Data and assessment information gathered throughout RATE's three years of life were also helpful.

What were some of the major findings?

First, most RATE graduates -- 92 percent -- said that they felt the courses they took met their needs in STD/HIV prevention work. In interviews participants praised a wide variety of course features, including working as a group, the careful planning devoted to each course, specific skill-building exercises and field trips.

On the quantitative side, the evaluation sought to find out whether participants had been able to conduct at least one HIV prevention program or related training after attending a RATE course; 76 percent answered yes. The remaining 24 percent responded that they were able to apply newly gained knowledge, skills and management competencies to their jobs.

Have RATE graduates advanced in their professions as a result of their training?

Many respondents -- again, 92 percent -- said their jobs had expanded to include a wider variety of HIV prevention activities. One out of three reported that they had been promoted since their training, with 27 percent of that group attributing promotions in part to their RATE experience. Many also cited increased self-confidence, job performance and personal effectiveness as further benefits of their training experience.

How are RATE graduates "redistributing" their new wealth of skills and knowledge when they return home?

Of course, the programs for which they work in their home country benefit from their new expertise. But one exciting development that we didn't really anticipate, something we learned in follow-up assessments and in doing the final program evaluation, is that their skills and confidence have so impressed their colleagues back home that many have been asked to give lectures and to start training other people. Now we're recommending that participants also receive training in presentation and training skills to satisfy this demand. A shorter training-of-trainers course would be very effective for this.

Is this demand for trainers primarily for BCC skill development?

Not necessarily. We're finding that RATE participants of all kinds are being asked to share their new knowledge with their colleagues at home. For instance, an Indonesian reporter who attended the "Facing the Facts" workshop for journalists told us that other reporters wanted him to organize a similar workshop back home, so we asked him to stay for two extra days for a cram course on presentation skills and curriculum development.

Did he make use of his new skills?

He created a very successful workshop for journalists in Yogyakarta and even organized an award for the best writing on HIV/AIDS, just as the RATE Program did. He has also given lectures on AIDS to university students. This man has far exceeded what RATE might have expected of him, and now we see the real potential for much more of that among our graduates.

How else can that potential be tapped?

We're also recommending that course work be developed in all of the languages of countries where participants come from. Regional RATE training in Thailand has been conducted in English, but we can extend our work by bringing the workshops right into the country, using graduates from the regional courses as resource people, trainers and facilitators. This approach would double the benefits of our regional training by strengthening what our regional graduates have learned through hands-on training of others, but also by helping to create critical mass in all the countries where we work.

What is critical mass?

This is one of my favorite terms in human resource development. It means having enough people in one place receiving training, mastering skills and gaining new perspectives that they're able to reinforce each other and build networks. It's always been a goal for RATE, but hasn't always been easy to achieve. For instance, we make a point of inviting two people from each country to each training session to support each other back home, but since they often live in different cities, they don't necessarily continue to communicate. In-country training could create critical mass much more quickly.

Does this mean, though, that the centers of excellence in Thailand will become less important?

Not at all. Training at the centers offers important educational dimensions not available at the country level. It helps participants develop a regional perspective and offers field study in Thailand, where both the AIDS epidemic and responses to it are more advanced than in other Asian countries. In fact, in-country training is assisted by the centers of excellence.

Have any networks emerged yet?

RATE alumni have in fact set up trainers' networks in India, Laos, Thailand, Cambodia, Nepal, Indonesia and the Philippines. AIDSCAP is supporting them by sending them HIV/STD training materials and manuals and copies of relevant studies in HIV intervention. I'm sure the number and strength of these networks will increase as more in-country training is developed.

Chalintorn Burian, Ph.D., a former staff member of the Program for Appropriate Technology in Health, an AIDSCAP subcontractor, was the training officer in AIDSCAP's Asia Regional Office in Bangkok, Thailand. She now serves as Southeast Asia regional director for the Institute of International Education.