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and Articles | DISH Distance Learning (DL) Strategy Document Background The mandate of the DISH II project is to build district capacity to ensure that facilities and service providers within the 12 project districts are offering high-quality, integrated reproductive, maternal and child health services. One of the ways that DISH II ensures that districts are prepared to provide high quality services, is to provide update training in existing reproductive, maternal and child health service (RMCH) areas. DISH II will also offer provider training in expanded service areas including: adolescent reproductive health (ARH), integrated management of childhood illnesses (IMCI), long-term and permanent methods (LT&PM), postabortion care (PAC) and emergency obstetric care (EOC). As part of their training mandate and to address the many diverse knowledge and skill needs of providers, the DISH II project wants to pioneer alternatives to classroom training to improve the performance of priority cadres of health workers within the districts. Since 1986 the Health Manpower Development Center (HMDC), based at Mbale and supported by the African Medical and Research Foundation (AMREF), has been offering a distance education program (DEP) to providers in six of the DISH districts. HMDC has developed resource and interactive materials for distance learners and guides for tutors. HMDC has also provided training for DL coordinators, tutors and clerks and developed a certification system. However, completion rates for HMDC courses have not been as high as anticipated/desired. An evaluation of the HMDC system revealed that the design for learner support is sound but that it rarely gets implemented as designed primarily because the tutors are not able to fulfil their role. The European Development Fund (EDF) also sponsors training for health care providers in six DISH districts and is interested in continued collaboration with DISH. The Family Life Education Project (FLEP) overlaps with DISH in two districts and is also eager to collaborate on training interventions. One of the provider cadres most in need of skills improvement are the nurse aides. Nurse aides provide over 50% of the services at primary health care facilities but have little formal training. To address this training need, the Ministry of Health (MOH) has made a commitment to train nurse aides. A three-month, hospital-based course has been designed and conducted for some nurse aides in some districts within Uganda. However, most nurse aides have not received the MOH training and may not receive this training in the near future. Although many of the participants in the HMDC/DEP courses have been nurse aides, these courses and materials are not designed for this cadre. DISH II is mandated to assist in the skill development of the nurse aide cadre. This cadre seems well-suited to DL opportunities. They have voluntarily participated in HMDC courses and due to a lack of formal training opportunities; they have developed the habit of learning new skills on-the-job. A distance learning intervention will offer nurse aides the opportunity to learn new knowledge and skills at their own pace without leaving their work sites. This approach has many benefits in addition to keeping the providers at the facility so that they can continue to provide services. In particular, when carefully designed, a distance learning approach will allow nurse aides to immediately apply what they are learning at their work site. The most successful distance learning programs include carefully designed learner support features such as mentoring, peer/paired learning opportunities, self-assessment, and interactive materials. In addition to improving clinical skills of providers, DISH is also mandated to implement a systematic supervision and quality assurance system at all levels of the health delivery system. This implementation entails working closely with the directors of district health services, district health management teams and the managers and supervisors of the facilities within the districts. DISH’s development of supervision/management capacity at district facilities in conjunction with HMDC’s existing distance education infrastructure can be used to provide the support necessary to provide learning opportunities for nurse aides and other cadres at their work sites. The DISH II project brings additional capacity for design and production of learning materials and job aides that can help to ensure good provider performance at work sites. To facilitate the development of a strategy to implement distance learning, the DISH II project convened a group of stakeholders in Kampala, Uganda, 26-28June 2000, to examine the possibility of using distance learning to improve the capabilities of health care providers. During the strategy development session, the participants:
Goal of DL Intervention To increase the quality and utilization of reproductive, maternal and child health services in DISH districts by improving the capacity of nurse aides to deliver basic reproductive, maternal and child health care. Objectives of DL Intervention
Conditions to Consider in the Strategy Design
Summary of DL Strategy The participants at the strategy development meeting agreed that DISH II should proceed with a distance learning course targeted for nurse aides. The first course will focus primarily on the provision of family planning services. The course will initially be implemented in three districts: Masaka, Ntungamo, Nakasongola. DISH II will financially support the development of the strategy design and course materials. Implementation of the course will be supported through sub-district grants. The course will be a mandatory requirement for nurse aides in these districts and learners will be allotted at least one hour per day of work time to compete course activities. As much as possible, mechanisms and materials already in place in the HMDC model will be used/adapted. DISH II staff will ensure efficient use of district resources in the development of learner support mechanisms by tying into other capacity building efforts such as improvements in supervision and management, other clinical training activities, and training/resource materials currently available or under development. It is expected that once established, the mechanisms used for the nurse aide course can also be used to train other cadres/content areas. DISH II staff will have primary oversight of the design and implementation of the strategy. Throughout the design and implementation DISH staff will:
The following is a step-by-step description of the design and implementation of the DL strategy. A summary chart of the work plan describing the activities, resources, timeline and responsible staff member is also included.
Build consensus and market the DL course A concept paper and a flier will be developed to document/market the strategy. DISH staff will make contacts with the HMDC director and key MOH staff at the national level and in the three initial target districts to explain the proposed strategy and gain their support for the proposed DL intervention. DISH staff will also build support for the DL intervention among other DISH districts that may benefit from a similar DL intervention and want to incorporate it in their work plan for the upcoming year. DISH will inform staff at the DISH branch offices and involve them as necessary in the design and implementation effort. Write behavioral objectives for the family planning course and develop a reference manual The position of nurse aide will be carefully examined to develop a detailed description of all the jobs and tasks performed by nurse aides. This description will be the basis of the behavioral objectives for the family planning course. Since this process takes a comprehensive view of the all jobs/tasks nurse aides perform, it is likely that the behavioral objectives for the FP course will cover some "foundational" knowledge and skills in addition to content that is specific to providing family planning services. The following is a list of possible/proposed topics for inclusion:
Other topics for possible consideration in the nurse aide training course series may include: safe motherhood, STD/HIV/AIDS, preparing the clinic for service, IMCI, growth monitoring, malaria prevention, nutrition (note: if other courses for nurse aides are anticipated, behavioral objectives for these courses should also be developed at this time). The development of the reference manual will be a collaborative effort requiring the services of subject matter experts, instructional/graphics designers, editors, and desktop publishers. Existing materials will be carefully examined and adapted if possible. The reference manual will be field-tested to ensure that it covers appropriate content, is based on actual job/tasks, contains only essential information (may also contain job aids), uses examples pertinent to learners, and is easy to read. It should be bound in a sturdy manner so learners can use it for reference after the course. Develop/adapt other materials Following the development of the reference manual, a learner workbook, guides for tutors and mentors and an orientation package for in-charges will also be developed. HMDC has already developed some materials for tutors that may be used/adapted. Similar to the development of the reference manual, the development of these materials will also be a collaborative effort requiring the services of subject matter experts, instructional/graphics designers, editors, and desktop publishers. An intensive multi-week work session will be convened for this process. The materials will consider/include the following:
Learner workbook (during design phase, consider other media in addition to print):
Tutors/mentors guidebooks:
In-charges orientation package:
Design the learner support and data collection systems DISH staff members with expertise in supervision/management and distance learning will work closely with the directors of district health services, HMDC/Mbale staff, and the district DL coordinators to design the specifications of the learner support system. It is expected that the course will be delivered in a manner similar to the one currently used by HMDC but modified using more decentralized mechanisms that improve learner support. The roles of HMDC/Mbale, the district DL coordinators, and clerks won’t change much from the current HMDC model. However, tutors will now be selected from the sub-district so that they are geographically closer to the learners that they are tutoring and the mentors that they are overseeing. A new role, that of mentors will be created. Tutors (and mentors) will be required to have good supervision/mentoring skills and a broad set of current clinical skills. Mentors will need to have time available for site visits (monthly supervisory visits) and review of the written exercises. A diagram showing the proposed design of DL delivery and learner support systems is attached. Identify and train district-based staff and deliver course materials In districts where HMDC’s DEP is not currently active, DL coordinators, clerks, tutors and mentors will need to be identified. In the district where HMDC/DEP is active, additional tutors based at the sub-district will need to be identified as well as mentors. All DL coordinators, clerks, tutors, mentors, in-charges will be trained/oriented prior to the start of the course by staff from HMDC/Mbale with assistance from DISH training staff. Deliver course and manage information The delivery of the course will begin after all DL support staff have been trained. Registration for the course will be conducted and a brief orientation for learners. In some districts the training course may need to have a staggered implementation to ensure that tutors/mentors have ample time/opportunities to support learners. Feedback mechanisms built into the materials and other monitoring information will be collected through the current HMDC data collection system. Data collected will be used to determine what modifications may be in order before the course is expanded to other districts. DISH staff will work closely with district and HMDC staff to ensure that implementation in the initial three districts is carried out as planned. Monitor and evaluate Prior to course implementation, DISH II’s monitoring and evaluation staff will identify specific areas of interest for evaluation (i.e., improved job performance, learner reaction to the DL approach). Periodic assessments of learner knowledge and skill will be built into the learner/tutor/mentor materials and schedule. Evaluations of the materials themselves (i.e., surveys/questionnaires) will be built into the learner’ workbook and the guidebooks for the tutors and mentors. Instruments and mechanisms for tracking additional indicators will be developed/adapted as necessary. Work Plan for Design and Implementation of the Strategy
DL Delivery and Learner Support System – Roles/Responsibilities Health Manpower Development Center
District DL Coordinator
Health Sub-district Tutor
Health Center III Mentor
Health Center II In-charge
Nurse Aides
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