Preview Chapter 6 Introduction

This chapter provides STD program managers with the information and tools they need to develop and sustain an STD training program for health care providers.

Planning Health Worker Training

To develop a plan for health worker training, take the following steps:

• Conduct a training needs assessment.
• Set course objectives and criteria for course participants.
• Select methods and techniques.
• Design each training session.
• Determine course participants.
• Determine resources needed.
• Develop an evaluation plan.
• Prepare a training proposal.

Training Objectives

Objectives should be behavioral and state what the learner should be able to do at the end of the course. Some examples:

• Participants using a flowchart will be able to diagnose and manage
• men with urethral discharge.
• Participants will be able to describe and demonstrate correct condom use.

Specific Topics in the Major Areas of Course Content

• STDs: transmission, control and the syndromic approach
• Clinical management of STDs using the syndromic approach
• Patient education for behavior change
• Partner management and reporting systems

Resource Needs

Both the human and financial resources needed for a training session should be identified. Cooperating with other public or private sector groups is a way to expand resources.

Sample exercises are an important resource for trainers to use. An example is the AWARE Scorecard (see Appendix 2), which helps to raise awareness about STDs and AIDS.

The Evaluation Plan

Managers should ensure that evaluation occurs in several different ways. Possible evaluation methods include the following:

• Knowledge pre- and post-tests
• Before-and-after attitude assessment
• Skill evaluation
• Participant feedback
• Trainer/facilitator evaluation

Successful Training: Key Issues

For training to have a long-term impact, it must have support that is sustaining. Some suggestions for helping to bolster training include:

• Arrange supportive supervision.
• Keep training short.
• Involve community groups.
• Stimulate continuing education.

Training for the Private Sector

Training also should be made available to private sector practitioners. However, sometimes they are difficult to access. Some possible approaches to this challenge include:

• Working with national medical associations
• Working with training centers to give recognition
• Providing mailings (e.g., newsletters and manuals)
• Writing key articles for regional or national journals

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IntroductionSTD managers play a critical role in supporting training programs that are well-designed and relevant to the needs of health-care workers, and this chapter discusses preparing them for this undertaking. Training providers is a critical component in promoting improved STD prevention and care. The chapter gives managers information about training resources, design tips and principles to guide their work with consultants or staff in designing training programs that result in improved STD case management.

Training health-care workers in STD case management is an ongoing process as more is learned about infections, effective prevention methods and better treatment techniques. Consequently, learning is a life-long commitment that needs continuing follow-up and supervision by managers, and openness and enthusiasm for new methods and materials by practitioners.

As more partnerships develop in future between the public and private sectors for STD prevention and control, sharing successful training methods and components will become more important to keep up with the challenge of training more trainers with potentially fewer resources.

STD Training Concepts

The Focus: Syndromic Management

The syndromic approach to STD management–early, effective diagnosis and treatment of STDs (described in greater detail in Chapter 8)–is designed to reach more people than are currently being treated using standard etiologic or clinical diagnosis. Syndromic management is based on the signs and symptoms with which a client presents and requires no laboratory support. A health-care provider is guided by a flowchart to the most effective treatment for a given set of signs and symptoms. With this simple technology and adequate drugs, the majority of STD clients can be treated by primary care workers at their point of first contact with the health-care system.

For trainers, the key to implementing the syndrome approach is the flowchart. Flowcharts, also called algorithms, bring together practical and scientific information for clinical decision making. Recommended treatment is based on knowledge of the most likely causative agents, distinguishing features of the disease and known patterns of drug resistance (see Chapter 8).

The use of flowcharts does not require that the health worker have an in-depth knowledge of causative organisms and drug sensitivities in order to arrive at a diagnosis. Ideally, prevalence and antibiotic sensitivity studies using regional or country data would have preceded the development of flowcharts for local use. Selected health workers presented with the data from these studies can arrive at a consensus as to the content of the flowcharts. If this approach is used, it is more likely that there will be a sense of ownership of the guidelines on the part of local health officials and health-care providers. Consensus meetings to review data and develop guidelines can be considered training in a sense, and those involved can be used in training others. This approach can greatly enhance the work of the trainer in promoting what is, perhaps, a new approach to the treatment of STDs.

The STD management flowcharts form the framework for the training that will also address the reasons for the flowchart recommendations, the clinical history and decision-making process, and the education component. One approach to promoting an understanding and familiarity with the flowcharts is to request that training participants, using the flowcharts, work on case studies prior to the training and during the training. Case studies can be used as pre- and post-tests, and for continuing education.

The Characteristics of Effective Training

This section discusses key characteristics that STD managers should look for when reviewing a training program or when seeking a consultant or organization to implement a training program. These training criteria are proposed as indicators of the appropriateness of a training program for the experienced health-care worker who also is an adult learner. The concepts might be new for some STD managers and the STD experts who may be asked to conduct the training. Many managers and physicians were educated or trained in traditional settings using didactic methods that are inappropriate approaches to training adult learners.

The training is competency-based

One characteristic of training that is intended to impart skills, such as training in STD management, is that the training be competency-based. This means that the training provides skills and knowledge needed to accomplish a specific task–in this case, STD management. The success of the training is judged by how well the skills are performed by the training participants after the course has ended.

How will an STD manager know if the training is competency-based? He or she can look at the agenda to determine if there is time for actual practice of skills. In an STD management course this practice would take the form of activities such as case studies and role plays. If the training agenda has a series of lectures with no practice, the STD manager should question whether the training will result in skill acquisition, which should be the goal.

How Adults Learn

Respect Immediate Use Experience Safety

The training follows principles of adult learningEffective adult training takes into account that the participants have experience and opinions that need to be respected and valued. This can be done by providing opportunities for the participants to share their knowledge and skills with the trainer and with one another. Discussions should be encouraged in which participants demonstrate problem-solving and have the opportunity to cite experience from which the knowledge is applicable to real situations.Other principles of adult learning include:

Needs assessment:This results in a training design that takes into account the level of understanding, readiness and experience of the participants. Listening to learners' wants and needs helps shape a program that is immediately useful. The question the manager and the trainer(s) should ask is: who needs what as defined by whom?Respect: This includes culturally appropriate courtesies and an attitude on the part of the trainer that conveys value for the participant as a person, a learner and an experienced worker. Respect includes a concept of the learner as the subject of his/her own learning.

Safety: Participants feel safe in the learning environment. They are not worried that their input will be ridiculed or judged harshly. It is the trainer's responsibility to provide a respectful response to participant input, thus enhancing the participant's feeling of safety. This will result in increased participation.

Sequence and reinforcement: The content and skills of the course are programmed in an order that goes from simple to complex and from group-supported to solo efforts. Reinforcement is the repetition of facts, skills and attitudes in diverse, engaging and interesting ways until they are learned.

Praxis: This involves doing something with new knowledge, practicing new skills and then reflecting on what has just been done. Case studies that invite description, analysis, application and implementation of new learning are an example of praxis.

Ideas, feelings, actions: There are three aspects of learning: ideas or knowledge (cognitive), feelings (affective) and actions (psychomotor). Training adults is more successful when all aspects are addressed in the training methods. Briefly, lectures are appropriate for conveying ideas; role plays and discussion for affective aspects; and practice, including role plays, case studies and problem-solving, for the psychomotor aspect.

Immediacy: Adult learners need to see the immediate usefulness of the skills, knowledge and attitudes that they are working to acquire.

I hear and I forget I see and I remember I do and I understand --Confucius

In STD training, health-care providers are required to be competent in comprehensive management of STD clients, including clinical care, health education and counseling. Competency-based training equips people with skills they can use for specific tasks.One of the truisms of learning is that we retain little of what we hear, a bit more of what we read, more of what we do and most of what we discover for ourselves. Building on this principle, participatory learning actively involves people and thereby ensures that they retain more of what they learn. In this participatory training style, active methods such as demonstrations, case studies and discussions are used more often than traditional lectures.

Participatory learning is based on the principle that the trainer poses problems for the learners that they work on together to solve. This builds on the principle that the trainers come with experience and knowledge. The methodologies that actively involve the participants are the most useful. Thus, lectures, which are used almost exclusively in traditional approaches to education, are used as little as possible when conducting participatory training.

Planning the Training

In planning the training of health workers in STD case management, it is useful to perform the following steps:

• Conduct a training needs assessment.
• Work with a local team to determine the criteria for course participants.
• Set course objectives
• Set training session objectives and design.
• Select training methods appropriate to the content of each session.
• Outline the resources for supplies, personnel and facilities needed, and specify the budget.
• Develop an evaluation plan that includes participant follow-up.
• Prepare a training proposal if funds are needed.

If possible, in developing a training plan, it is good to work with a team composed of the STD manager, a provider and an experienced trainer. This team approach ensures that the training is designed and implemented to maximize adult learning, meets the needs of the STD program, is technically sound and can be accomplished.

Conducting a Training Needs Assessment

In planning competency-based training, it is important to identify the skills participants will need to manage patients according to the syndromic approach and determine the current level at which they are in command of these skills. In addition, the need for specific skills at different levels must be defined according to the setting in which the worker practices. For example, health workers in a primary care setting might have experience managing STDs using the clinical approach and minimal practice or training in using the syndromic approach and doing prevention counseling. On the other hand, workers in a family planning clinic might have little experience with STDs and all other components of STD management. The course would have to be designed to meet the needs of both types of participants if they were to be included in the same course. In other words, the setting in which the participants practice, including constraints and available resources, is information that should inform the training plan as well. Assessing the skills being performed competently as well as those that need strengthening is essential.

To determine which skills must be addressed in the training, it is necessary to define the function the participants must perform in their work setting. The functions providers must be able to perform in order to use the syndromic approach to the management of STDs are several. Though not exhaustive, the following is a sample list of these functions:

• History-taking and risk assessment
• Recognition and management of signs and symptoms and complications of STDs
• Patient education and preventive counseling

The performance of these functions requires more than factual knowledge. There are skills germane to each of these functions. For example, history taking requires interviewing skills, and patient education for STD prevention requires skills in condom demonstration and behavior change advising.

Assessing participants' current practices in STD management can be done by interviewing health-care providers, supervisors, clients and other community members about what is currently done in managing STDs and how current practices are perceived in terms of effectiveness and acceptability. This information can be used with information from clinic records about the way in which STD clients are currently managed and what areas need to be improved. With the aid of checklists, direct observation of health-care providers can help determine how clients are treated. Checklists can be used in assessing how and what elements of the history and physical examination are currently performed, how the promotion and distribution of condoms is being handled, and what the prescribing practices are.

In addition, it is important to assess what is being taught in the basic curricula of medical and nursing schools in the public health approach to STDs. Incorporating concepts of syndromic management and prevention counseling into basic programs could serve to improve overall practice.

Overall Course Content

This section addresses the general areas of STD case management that are appropriate for inclusion in training programs in most countries, with individual variations. The major content areas that the training should address are:

• STDs: transmission, control and the syndromic approach
• Prevention education and behavior change
• Partner management and reporting systems

STDs: transmission, control and the syndromic approach gives the health-care worker a background in the public health perspective on STDs. Whereas many training workshop participants may have experience treating individual patients with STDs, many will not have had the opportunity to learn about STD epidemiology and what is required at the community level to change the prevalence of STDs. This content is important in motivating participants to use the syndromic approach because it places the problem of the STD patient–the individual infection–in a community context. The provider is challenged to do more than deal with each individual case, but to be a part of a larger community effort involving partner management, reporting and prevention of repeat infections.

In addition, many providers who have been using the clinical or etiologic approach to STDs have a strong need for information about the local STD prevalence, related risk factors and drug resistance issues, including specifics about which locally available drugs are the most effective. Information about local policies and procedures for partner management and reporting is also needed.

Prevention education and behavior change is a critical part of the case management approach, though it is often omitted in busy clinics. While it is understood that many clinicians are not oriented to counseling or patient education, it is important that managers and providers be aware of the important impact these efforts have on behavior change in regard to STD prevention and treatment. Although clinicians and managers may not do the actual education and counseling, their support and facilitation of others who are trained and interested in this are critical.

Partner management and reporting systems are essential to the effective control of STDs. All reporting, including any information regarding partners, must be confidential. The training content should address partner notification and reporting in the general context of how they fit in with prevention and control efforts, and there also should be specific instruction on local policies, procedures and reporting systems.

Training Objectives

The course objectives should be behavioral in nature in the sense that they should state what the learner should be able to do at the end of the course and be measurable. Objectives should describe behaviors participants will be able to demonstrate, skills they will be able to perform or knowledge they will be able to use as a result of their course participation. The described behaviors should be measurable, feasible and relevant. For example, instead of using the verb "to know," which cannot be measured, trainers might use verbs such as "to list," "to describe" or "to discuss" that are measurable. For example: "At the end of this session, participants using a flowchart will be able to diagnose and manage men with urethral discharge." Here are some examples of possible course objectives:

• Participants will be able to recognize and manage appropriately the STD syndromes of urethritis, genital ulcer disease, vaginal discharge and pelvic inflammatory disease.
• Participants will be able to describe and demonstrate correct condom use.
• Participants will understand the importance of patient confidentiality and be able to cite ways to ensure it.

These more general objectives can be broken down into more specific objectives for each session. At the beginning of each course and each session, the trainer should explicitly review the objectives with the participants.

Training Methods

As mentioned above, adult learning methods are likely to be the most effective when training experienced health-care workers. It is recommended that the trainer employ participatory techniques that actively engage the learner. These might include small group discussions, demonstrations, role plays, case studies and simulations.

In planning the training, the trainer must identify the most effective teaching method for the type of content being covered in a session. In other words, the method should match the domain of learning (is the domain of learning cognitive, affective or psychomotor?). The lecture is a method often used in medical training workshops. Its methods are really only suitable for the transfer of factual information. It is not the most effective way to teach skills such as history-taking, physical examination, problem-solving or diagnosis. These are best addressed by methods such as case study, role play, group discussion or actual practice with feedback. (The areas of learning domains and teaching methods are discussed in greater detail in Chapter 10.)

Trainers encourage and facilitate the educational process by illustrating learning experiences, providing feedback, summarizing important points, challenging participants and pacing the introduction of new material. Supervised field experience during or shortly after a workshop may be the single most important way to acquire the skills, attitudes and knowledge needed to use the STD flowcharts. Such field experience involves having a trainee manage patients with STDs in a clinic in collaboration with a trained supervisor. Follow-up supervisory visits should be planned for in conjunction with the STD program manager and are an essential part of training.

To be effective, field experiences need to be carefully organized. The supervisor should be trained in appropriate supervision techniques and should use observation checklists to assess the trainees' work. For example, in Tanzania, that the trainees spend three to five days immediately following a workshop under the watchful eye of a trained supervisor has resulted in a marked increase in their effectiveness. Follow-up supervision at a later time, such as three or six months after the training course, has also proved effective.

Specific Topics in the Major Areas of Course Content

STDs: transmission, control and the syndromic approach: The level and amount of detail in which this area is addressed is determined the needs assessment and should take into consideration factors such as the background of the health workers. The needs assessment is the key to targeting the level at which the content is taught and the amount of detail appropriate for the participants. In general, the content in this session includes:

• Local epidemiology of STDs
• Factors affecting transmission of STDs
• The relationship between STDs and HIV
• The complications of STDs
• Factors affecting STD risk and prevention
• Local beliefs and practices about STDs

Clinical management of STDs using the syndromic approach: The manner in which this area is dealt with is critical to the success of the course. It is understood that participants have been practicing in the best way that they know how. Trainers should be sensitive to the difficulties of suggesting that clinicians change the way in which they approach their professional practice. Exploring attitudes toward the syndromic approach might help avoid pitfalls of participant resistance. In general the syndromic approach should be put in the context of public health goals and not couched simply as an approach that works when there are not enough resources to do STD laboratory tests. The aspects of clinical management using the syndromic approach that should be addressed include:

• The syndromic vs. clinical vs. etiological approaches to managing STDs
• History-taking and the physical exam in assessing patients for STDs
• The syndromic approach and how it fits into a public health approach to STDs
• The use of flowcharts in managing STDs (advantages, disadvantages and techniques for successful application)
• Risk assessment for STDs
• Specific STD syndromes: assessment and management of vaginal discharge urethral discharge, genital ulcers, lower abdominal pain, infected eyes in newborns

It is understood that participants should already have a basic knowledge of male and female anatomy and the general facts about the transmission of sexually transmitted diseases. However, many will have been trained years ago and may have had little opportunity to update their knowledge. Thus, they might not be familiar with more recently identified STDs such as chlamydial infection, or with new antibiotics. In addition, many providers might not have experience, personal or otherwise, with condoms.

Patient education for behavior change: The goal of behavior change and communication strategies is to prevent STDs. Communication strategies are important in teaching new information and correcting old myths (see Chapters 4 and 10). And since anyone being treated for an STD remains at risk of acquiring another one, the treatment process itself provides an excellent opportunity to educate to reduce further episodes. Patient education is a crucial part of any STD control program and, therefore, needs to be part of every contact between a health-care provider and an STD client. The focus of patient education for behavior change is in the following:

• Enhancing health-seeking behavior. (People seek out health care when it is of good quality. So first improve the quality of health services provided.)
• Early symptom recognition and treatment
• The 4 Cs: contact tracing (or partner referral), condoms, counseling/education and compliance

The content that should be addressed in this area covers the knowledge and skills that health-care workers need to influence client behavior. This includes cognitive information and behavioral skills. (Full discussion of the important messages to be communicated to STD clients can be found in Chapter 10.)

Cognitive information includes:

• Knowledge of the social and behavioral elements related to the patient population, causative and preventive behaviors, and an awareness of knowledge, attitudes, behaviors and myths related to STDs (see Chapter 13)
• Data about current STD prevalence and utilization patterns of health services
• Facts about condom effectiveness (and, if possible, a demonstration of condom use), posters, brochures and videotapes (see Chapter 5)
• Information about the importance of complete patient management, not just drug treatment. (Management for each client should include the 4 Cs: contact tracing, condom use, counseling/education and compliance. Clients need to know how they acquired the infection, about symptoms so they can report early for treatment, and about the importance of completing the full course of treatment.)

Behavioral skills include:

• Ability to talk about sexuality and sexual behavior with self-confidence, so people are comfortable discussing these issues with the health-care provider
• Interpersonal communication skills to facilitate client relationships, speaking the same language and being able to personalize health messages, and the ability to project a positive attitude toward STD clients
• Counseling skills, including how to assess a client's risk during an interview, how to negotiate risk reduction, and how to provide client-centered counseling. (Counselors need to allow for client differences in beliefs, values and behaviors.)
• Ability to demonstrate condom use and assist in client acceptance of condoms

Conducting a Training Needs Assessment

• Influences on health behavior: social norms, media, beliefs and attitudes
• Why sexual behavior is difficult to change
• Approaches to behavior change
• The role of the health-care provider in behavior change
• Strategies for motivating patients to change behavior
• What patients need to know about STDs and how to explain it
• How to improve compliance with treatment recommendations
• Overcoming barriers to compliance with drug treatment instructions

Community health workers can help spread the message that early treatment is important. They can also demonstrate how to use condoms, help make condoms more accessible and initiate discussions about sexual behavior in the community. The STD training programs should teach health workers the skills they need to work with communities and ensure that health-care providers have an opportunity to use their new skills.

Teaching methods for these topics should provide skills practice through role play and case studies. Sample role plays can come from the participants themselves. The role plays should be brief with very clear directions from the trainer about the communication skills that are being practiced followed by feedback that addresses what was done well and what might have worked better. The feedback should be directed to the specific behaviors demonstrated. The element of safety is critical to the use of role plays. The trainer needs to facilitate in such a manner that participants feel confident and are given feedback in a respectful way.

Dealing with patients with STD. especially HIV/AIDS, can cause great concern and even fear in health workers. Unless such fears are dealt with, the knowledge gained in the workshop will not be put to use. Recognizing and discussing such fears can help put them in perspective.

Partner management and reporting systems:Partner management issues (see Chapter 11) are a part of the prevention counseling session as well, but the systems put in place locally to deal with partner tracing or contact information are additional aspects that should be addressed. In addition, reporting of STDs is an important issue in STD control. The data gained at clinics becomes a part of the national statistics. This then helps to set priorities in dealing with STDs, identifying essential drugs and tracking the success of prevention and control interventions.

The general topics that should be included are:

• The importance of partner management to STD control
• Approaches to partner notification
• Working with patients to notify partners
• Reporting:
  • Reporting STD cases: local approaches, local needs
  • Confidentiality issues, interviewing, partner management and reporting

If a reporting form exists to monitor STD cases, the program manager should ensure that it is consistent with the training materials. It is not uncommon for the training to be oriented to the syndromic approach and the reporting forms to specify a specific etiologic diagnosis. The completion of these health information system forms should be included in the training.Many countries have a national health information system form for all types of visits. Modifying this form to reflect the syndromic approach is neither easy nor inexpensive. Often there is no optimal solution to training in syndrome management and using old reporting forms. The need for the information (see Chapters 14 and 15) and the extra burden to the health provider of additional reporting forms if the current ones cannot be easily modified needs to be taken into consideration. (See Appendix 1 at end of chapter, an example of a patient encounter form that reinforces the syndromic approach.)

Training Session Design

Once training needs have been assessed, using the session content as outlined above, trainers can design session objectives, contents and methods. Each session design consists of a title, objective(s), background section, outline of content and methods, time required and a list of resources needed. (See Box 1 for illustration of sample lesson plan).

Many of the books written about STDs are inaccessible to the majority of health-care providers because they use highly technical language and are expensive. The World Health Organization (WHO) and several countries have developed STD training manuals. Some are written to be used outside of a workshop setting. Given the time and expense of most workshops, alternative approaches are recommended when possible. Some examples of alternatives are self-learning modules, similar to the new WHO manual on STD case management. Self learning modules offer options such as: (1) individual review of the manual, followed by group meetings with a facilitator, or (2) group review of the manual with a facilitator. These sessions can take place for an hour or two on a work day at the clinic or on a day away from the clinic monthly, until the content is covered. Much of this depends on the manner in which syndromic management is being introduced to the clinic setting. If there is rapid implementation planned, this might not work, but if there are providers employing the syndromic approach and others are being gradually "brought on board," this long-term training approach might work.

The recommendations in manuals written for individual countries can be adapted to the local circumstances in areas such as antibiotic recommendations and referral patterns. Many of these manuals have facilitator guides that provide background information on each topic as well as suggestions for optimal use of the session.

Trainers may have to develop additional lesson plans to address specific needs that become evident during training. In Kenya, for example, trainers noted that health workers believed high-risk sex behavior was a problem for high-risk groups but not for others. To address this misconception, exercises were developed in the classroom to dispel this notion and to raise awareness of broader personal risk.

When incorporating new material or combining sessions, trainers often try to cover the same amount or more material in less time. As a result, none of the material is absorbed fully. To avoid this mistake, trainers should review the learning objectives each time they revise a session. It is also important to allocate time in the training schedules for writing reports of the workshops and for training the trainers. A decision should be made on whether to have an orientation workshop prior to training. An orientation workshop can ensure that the key people involved are aware of the program, advised of their roles and supportive of the health-care providers.

Selection of Course Participants

In developing countries, the majority of STD clients are treated by auxiliary health workers. However, in many countries, doctors in private settings also provide care for many people with STDs. If new approaches to case management are being used, private practitioners might want to learn about them. Furthermore, doctors can be more supportive of the efforts of primary health-care workers if they are aware of their activities. Doctors also can be influenced to provide more and better STD health education and counseling.

Physicians can be contacted through their professional associations. Presenting a paper at a conference, mailing out pamphlets and posters, and holding short workshops are other ways to reach out to physicians.

Training in sexuality and sexual behavior appears to work best in mixed groups of male and female health workers. Such groups reflect the way in which people live and work. Experience suggests that mixed groups can stimulate honest interaction and openness on the issues surrounding sexual behavior, but this is something that should be decided at a local level.

The Role and Selection of Course Trainers

To sustain skills learned at the workshop, it is important for health-care providers to have continuing support and supervision in the field. Training does not stop when the work ends. It is an ongoing, life-long process. If possible, select as trainers people who will be supervising the health-care providers. This will also help supervisors update their own knowledge through training of trainers sessions.

Adult education and participatory learning methods are often new to the trainers, so it may be necessary to provide training of trainer sessions. It is often useful to involve as trainers those who already have training skills, such as tutors from basic training schools or trainers from nongovernmental organizations that operate primary health-care projects. These trainers can share their skills and experience in training health workers with others who are learning to train for the first time. In addition, as a result of their exposure to the new STD training material, tutors may be able to incorporate some STD workshop material into classes they already teach or stimulate curriculum change within their schools. And it may be possible to involve them in regional refresher courses, augmenting the input of the district health team and health unit supervisor.

The Role and Selection of the Course Facilitator

In order to have a well-organized course that consistently follows the session designs and uses participatory methods, with attention to the safety and comfort of the participants, it is important to select a skilled facilitator. The role of the facilitator is more global than that of the individual trainers, a term used here to refer to presenters. The facilitator should be familiar with the course and, ideally, will have worked on its design. The facilitator should be skilled in ensuring that the trainers and the participants progress toward the course objectives, play a key role in maintaining a participatory format and deal with issues as they arise. For example, if it becomes evident that participants are having difficulty with the content or are hesitant to participate, it is the role of the facilitator to intervene with the trainers to resolve the matter.

In many situations the facilitator might be referred to as the lead trainer or course organizer. Whatever the term, the presence of the facilitator is key to the success of the course. The person should be respected locally and be knowledgeable, though he or she does not necessarily have to be considered an STD expert. The importance of diplomatic, group management and training skills supersedes the importance of technical knowledge for the purpose of the role as course facilitator.

Resource Needs

Both the human and financial resources needed for a training session should be identified. Scarce training resources can be stretched farther through cooperation with others. In Uganda, for example, regular coordination meetings involving the Expanded Program of Immunization as well as the Continuing Education, Control of Diarrheal Diseases and Essential Drug programs, resulted in optimal use of limited training resources. Coordination of training by these programs minimized the time required for district teams to be absent from their posts for training. It also eliminated duplication of content in training courses.

If other training programs such as the Expanded Program for Immunization or the Essential Drug Program have carried out training of trainers in a district, potential trainers already may have acquired basic training skills and may only need to be provided with STD material. If a rural health training school is nearby, its tutors could be involved as trainers.

Early attention to the venue of workshops, per diems and out-of-pocket expenses can help managers avoid problems. Managers should be aware of what other training groups working in the country are doing.

The support and supplies needed for the application of new skills should be in place by the time health workers return from their training so they can use their new knowledge and skills immediately. These resources include a regular supply of drugs, a functioning referral system, a health information system and trained supervisors. Needles, syringes, test tubes, gloves and specula, as well as a way to sterilize them, may also be needed, depending on the nature of the algorithms to be used. Also, it is important to have on hand a supply of materials that reinforce the training such as flowcharts, wall posters, and provider-patient encounter forms.

One example of resources is sample exercises for trainers to use. Especially for trainers who are accustomed to using the lecture method, it is helpful to provide exercises that make it easier for them to use a more participatory approach. These can be included in the lesson plans. An example of a tool for this type of training and for clinical practice is the AWARE Scorecard, which can be used to raise awareness about the risk of STDs and AIDS (see Appendix 2).

The Evaluation Plan

To get the best results from training, managers should ensure that evaluation occurs in several different ways. Possible evaluation methods include knowledge pre- and post-tests, before-and-after attitude assessment, skill evaluation, feedback from participants and facilitator evaluation. Evaluation indicators should include process measures, such as the number of workers trained and the number of courses held, and outcome measures, such as the number of clients being managed appropriately and the number of contacts brought in for treatment.

Evaluating Gains in Knowledge: Pre- and Post-Tests

Conducting a Training Needs Assessment of knowledge gained and its use in solving problems can be evaluated through multiple choice questions given before and after training. It is useful to have one or two questions on each topic covered in the workshop. Detailed item analysis of each question can help trainers determine whether there are problems with the question itself or whether the material has not been learned. For example, detailed item analysis assesses the number of people who get the question right to start with and wrong afterwards, or wrong at the beginning and right afterwards, and so forth. Getting the question wrong afterwards could indicate that the manner in which the material was presented generated confusion rather than greater understanding or clarity. Trainers can measure the difference between the pre- and post-test scores to calculate the increase or gain. It is also possible to calculate an "adjusted" gain by dividing the gain for each person by the maximum possible gain he or she could have achieved.

                Post-test = Pre-test score

Adjusted Gain = -------------------------- x 100          

                  100% - Pre-test score 

Measuring Changes in Attitude and Perceived Competency

Provider competency in fulfilling their role in STD management, as well as attitudes and perceptions about patients, can be measured through focus group discussions, observation and personal interaction with participants. A brief, standardized attitude questionnaire may also be useful. To measure perceived competency in performing the skills described in the behavioral objectives, it is useful to do a before and after self-rating by participants. Examples of several appropriate statements include:

• I am comfortable using flowcharts to treat patients with a vaginal discharge.
• I am comfortable conducting a risk assessment with patients.
• I can identify the major types of STDs that cause vaginal discharge, urethral discharge and genital ulcers.

These statements are then rated from "agree strongly" as a 5 on the scale, to "disagree strongly," 1 on the scale. The goal is that perceived competency will increase from the pre-workshop to the post-workshop measure.

One of the most important ways to ensure that health-care providers have been well trained is to visit them some time after the course and observe how they manage STD clients. Trainers or supervisors should use an observation checklist (See Box 3) to help them provide objective feedback. After observing a health-care provider's compliance with the items on the checklist, the supervisor then should discuss each item with the provider and give an objective assessment. Items that have been done well and areas that need improvement should be reviewed.

Health-care providers can assist in preparing the observation checklists. Checklists allow supervisors to provide objective feedback and should be limited to no more than nine items. The presence of too many items only discourages both the supervisor and health-care provider. When a health-care provider has demonstrated mastery of the first nine items, other areas can be added. Key items for an observation checklist could include the following:

• Taking a relevant history, and conducting a regional physical examination of the genital area related to the presenting symptoms in men and women
• Examining the eyes of a newborn baby
• Applying ointment to eyes of the newborn
• Conducting an abdominal exam in women with abdominal pain to assess tenderness, guarding and rebound tenderness
• Diagnosing and treating key STD syndromes using flowcharts (e.g., vaginal discharge, urethral discharge, genital ulcers, lower abdominal pain in women and infected eyes in newborns)
• Encouraging clients to:
  • seek treatment early for STD symptoms
  • use condoms
  • refer partners
  • avoid self-medication
  • complete the full course of treatment
  • refrain from sex until cured
• Counseling clients on sexual risk reduction

Assessing health-care providers at their work sites also will provide information that can be used in future training sessions, such as additional topics or specific areas that need more emphasis.

Participant Feedback

Participant evaluations at the end of the workshop can be detailed and comprehensive, covering individual sessions and daily activities, and indicating degree of satisfaction with the training.

During the course, participants should be encouraged to comment on individual sessions as well. Trainers should keep such feedback simple and vary the format and style to bring out the main points that need to be addressed during the course. For example, they could ask what was most and least useful about one session and, after another session, whether trainees' opinions were valued and how. Suggestions can help trainers make changes during the course and improve future courses. Use of forms may improve feedback. Many trainers have found it useful at the end of each day to have the facilitator lead the group through a summary of "what went well" and "what didn't go well," using a flip chart to keep track.

Another useful device to capture issues and questions during the course of the workshop is to have a piece of flip chart paper on which participants and trainers can write unresolved or end-of-the-day questions that need to be addressed prior to the conclusion of the course. This frees the trainer and facilitator from having to remember each one and provides participants with the sense that the questions they have raised are important and respected.

Trainer and Facilitator Evaluation

Besides getting feedback from participants, trainers and facilitators should evaluate themselves using self-scoring lists. They also should provide feedback to one another in a supportive way so they can assess how the course is going and make changes as needed. Daily facilitator meetings not only help keep training on track, but also provide an opportunity for facilitator interaction and growth.

Participants also can evaluate the following course components:

• Venue
• Organization
• Quality of presentations
• Quality of participant participation

In evaluating trainers, participants should be directed to assess elements such as clarity of presentation, interest in the presentation, and responsiveness to participants' questions and concerns.

Successful Training: Key Issues

Follow-up and supervision

Training that is a one-time effort or that is not put into practice can waste precious human and financial resources. As mentioned earlier, the support of clinic supervisors is critical to the impact of the training on actual practice and the improvement of STD case management. In addition, supportive supervision can contribute significantly to the providers' continued application of new skills and principles. When participants are not able to apply new skills and information, they can become demoralized and training can lose its credibility. Thus, during the planning phase, the STD manager, clinic supervisors and trainers should plan a follow-up to the training.

If necessary, the supervisor should be trained in the skills and attitudes needed to provide appropriate, supportive feedback. Supportive supervision means that a supervisor gives encouragement and positive feedback, identifies weaknesses and assists health-care providers in carrying out what they have learned. Supervision, which is influenced by the local situation, requires familiarity with the local situation, and empathy with health-care providers.

Although it is generally recognized as the most important aspect of ensuring quality care, supervision is often neglected. This may be a result of constraints on transport and/or on adequate staffing. Success may be achieved by using exceptional, experienced workers as supervisors.

In many STD control programs it may be possible to have health-care providers from the STD referral center visit outlying units to augment supervision. One caution about using single-purpose health workers as supervisors for multipurpose primary health-care workers is that they may undervalue and underestimate the time and effort required for other aspects of a multi-purpose health worker's job description.

Length of Training

In most primary health-care units, STDs account for less than 10 percent of clients' health problems. Health-care providers who are required to manage 20 or more common diseases cannot spend too much time on one disease. In addition, governments generally cannot afford to extend continuing education programs to all health workers or to upgrade their skills regularly with lengthy training programs. What is too lengthy varies from country to country, but often any course that exceeds three to five days is considered excessively long. To maximize support for STD training, workshops should be efficient and accommodate clinic demands. As mentioned above, alternative approaches to workshops are also recommended. Periodic seminars over a defined period with self-study sessions are one option.

To illustrate, the two-day in-service training for health workers in Kenya included a brief exposure to the following topics: public health importance of STDs; management of ophthalmia neonatorum, genital ulcers, vaginal and urethral discharge, abdominal pain in women and antenatal syphilis screening; team building; condom demonstration; clinic simulations; communicating health messages; and community interaction. It was possible to introduce and provide some practical exposure to each topic.

Often trainees will ask for more time and trainers often may feel they need more time. But much can be covered in two to three days that can improve client care. This is true especially when training is followed by field experience and continuing supportive supervision.

Continuing Education

Learning is never over. It is a lifelong commitment. Here are two techniques to stimulate continued learning:

• During the workshop, identify areas in which participants want to continue to work such as developing their counseling techniques, or learning more about STD prevalence or improving reporting forms. Time can be set aside during a meal or break at the training to brainstorm ways in which participants can continue to learn.
• Ask trainees to consider how they can continue updating their knowledge and skills. For instance, they may decide to meet for half an hour each month and ask a staff member to review the management of a difficult case.

Distance learning courses have been very effective in sustaining learning that began at short workshops. In Uganda, during times of insecurity when the postal and telephone service did not work and health units were closed, health-care providers continued their distance education lessons. Local arrangements kept the lessons moving between the district health offices and the Center for Health Manpower Development.

Distance learning includes correspondence courses, radio shows and face-to-face workshops. If distance education is already provided for health workers in your country, discuss the possibility of developing an STD course based on your training. If STD training is not offered, stimulate interest and activity in the area. The African Medical and Research Foundation (AMREF) in Nairobi, Kenya, an NGO specializing in primary health care, provides distance education courses to health workers in several East African countries and is currently developing STD courses. Short refresher courses of one or one half day can be used to upgrade and solidify skills, discuss problems and enhance motivation every one to two years.

Training for the Private Sector

Although private sector practitioners may be difficult to reach and often lack the time to attend training sessions, making available continued medical education and skills upgrading to them remains essential.

Possible approaches to the challenge of providing training for private sector practitioners include:

• Working with national medical associations
• Working with training centers to award diplomas or other forms of recognition
• Providing mailings in the form of newsletters and self-instructional manuals
• Writing key articles for regional or national journals

Reference Materials

The availability of books is an important determinant of continued learning. If possible, clinics should provide simple reference manuals for the health units. Currently, programs in many countries are developing expertise in local production of such manuals through the Health Learning Materials Network of WHO.

Ongoing access to sources of current information about STDs, including HIV/AIDS, is critical for anyone planning an STD training course. Sources of training materials, including books, are provided at the end of the chapter. Also listed are a number of newsletters with current information, suggestions and articles from many countries that include information about STD and AIDS. Many are free in the developing world.

Appendix 2

Risk assessment is conducted one-on-one between the health-care provider and client. It is done interactively, drawing on what the client knows and thinks. A trainer can model how to help providers put risk assessment into a positive context by working with them to develop an introductory statement that does the following:

• Ensures confidentiality
• Expresses empathy that the topic is sensitive and difficult to discuss
• Stresses the importance of accuracy

This discussion is a vehicle for helping the client come to believe that the risk of infection is important. It also assists the client in accepting that his personal behaviors are directly connected both to real risks and to risk reduction.

Counseling about risk reduction is undertaken after risk assessment has been completed. The AWARE Scorecard on risk reduction may be helpful as it outlines in descending order the main risk-reducing sexual practices.

References

1. Brief reference for the diagnosis and treatment of sexually transmitted diseases. Research Triangle Park, North Carolina: AIDSTECH/Family Health International, 1991.

Suggested Readings

1. Abbatt FR. Teaching for better learning. Geneva: World Health Organization, 1980.
2. AIDS/STD education and counseling in Africa. Research Triangle Park, North Carolina: AIDSTECH/Family Health International, 1992.
3. Bower B. Werner D. Helping health workers learn. Palo Alto, California: Hesperian Foundation, 1986.
4. Gordon G. Klouda T. Talking AIDS: a guide for community work. International Planned Parenthood Federation. Macmillan, 1988.
5. Johnson M, Rifkin S. Health care together: training exercises for health workers in community-based programmes. Macmillan, 1987.
6. Lynch E, Gordon G. Activities to explore: using drama in AIDS and family planning work. London: International Planned Parenthood Federation, 1991.
7. Training Department. Continuing education for health workers. Nairobi, Kenya: African Medical and Research Foundation, 1983.
8. Vella J. Learning to teach: training of trainers for community development. Westport, Connecticut: Save the Children Fund/OEF International, 1989.

Training Resources

Appropriate materials including books for health workers can be obtained from:

1. Soundings, World Neighbours, 4127 NW 122 Street, Oklahoma City, OK 73120
2. TALC, Teaching Aids At Low Cost, Box 49, St. Albans, Herts. AL1 4AX, UK
3. AMREF, African Medical and Research Foundation, Box 30125, Nairobi, Kenya

Newsletters

There are also a number of newsletters dealing with STD/AIDS, training and PHC issues with up-to-date information, suggestions and articles from many countries. All are free in the developing world and you can receive them regularly for the cost of a stamp.

1. AIDS Action, AHRTAG, 1 London Bridge St. London SE19SG, UK
2. AIDS Health Promotion Exchange, WHO, 1211 Geneva 27, Switzerland
3. Contact, Christian Medical Commission, 150 route de Ferney, 1211 Geneva 2, Switzerland
4. Health Action–Implementing PHC Worldwide, AHRTAG, 1 London Bridge St. London SE19SG, UK
5. Strategies for Hope, Action Aid/AMREF/World in Need, TALC Teaching Aids at Low Cost, Box 49, St. Albans, Herts. AL1 4AX, UK
6. World AIDS, Panos Institute, 9 White Lion Street, London, N19 9PD, UK