Integrated Management of Neonatal and Childhood Illness Training in Lao PDR: A Pilot Study of an Adaptable Approach to Training and Supervision

ABSTRACT.

Integrated Management of Neonatal and Childhood Illness (IMNCI) has been part of the national strategy for child health in Lao Peoples Democratic Republic since 2003. The program, while running for an extended period, has faced multiple challenges including maintaining the teaching quality for the implementation of the IMNCI guidelines and a structure to enable and support healthcare workers trained to apply the training in their workplace. A revised training model that focused on building skills for teaching according to adult learning principles in a pool of facilitators, a practical and hands-on training workshop for healthcare workers, and the establishment of a program of health center supervision was developed and implemented in three provinces. Participants in the revised model reported increased confidence in implementing IMNCI guidelines, they demonstrated competence in the steps of IMNCI and on follow-up assessment at a supervision visit were found to have improved patient care through the measurement of pediatric case management scores. This study highlights the importance of a focus on education to ensure the translation of guidelines into practice and thereby lead to improvements in the quality of pediatric care. The IMNCI training approach is acceptable and valued by healthcare worker participants.

INTRODUCTION

Lao PDR (or Laos) is a land-locked low-middle-income country in south east Asia¹ which is currently transitioning in focus from quantity of healthcare providers to improvement in healthcare service quality.² A key area to be addressed is the strengthening of educational systems to promote competent healthcare professionals.^2,3 Identified challenges include a shortage of qualified clinical educators as well as inadequate resources and limited budgets in educational institutions.⁴ Moreover, there is uneven distribution of the health workers, and half of the existing staff in health centers are low-level health workers, who require capacity strengthening.⁵ Consequently, in-service training remains critical to build skills necessary for the programs that support the national strategy for child health such as Integrated Management of Childhood and Neonatal Illness (IMNCI), Early Essential Newborn Care (EENC), and the Pocketbook of Hospital Care for Children (The Pocketbook). The impact of these programs is dependent on how they are implemented, the teaching skills, and the availability of the pool facilitators and resources to implement the programs on the ground.

IMNCI is designed to impact child health outcomes through case management training for primary healthcare workers, strengthening healthcare systems and improving household and community behaviors such as breastfeeding.⁶ However, IMNCI has faced challenges in its implementation globally⁷ including the cost of implementation that has traditionally included long case management training and the need for ongoing follow-up for supervision.⁸ In Laos, IMNCI implementation began in 2000⁴ with healthcare workers trained across the country in one-off trainings between 2002 and 2008 and the program became a component of the national healthcare strategy since 2016. However little is known about the impact of this program on care in this setting.^4,9

IMNCI training was originally designed to provide knowledge and opportunity for practice using training content with feedback, allowing a minimum of 30% of training time dedicated to practice and a trainer to participant ratio of less than 1 to 4.⁶ The reality of IMNCI implementation in Laos, as elsewhere,⁶ is that gradual reduction of training time (from 11 days to 5 days in Laos) has led to the dominance of didactic approaches (lecture and reading) over opportunity for interactive practice. There has been a focus on training without systematic planning for reliable access to essential medicines or the supervisory support afterward to ensure ongoing capacity building and application on the ground. These challenges in Laos are reflected in the implementation of IMNCI globally,^7,8,10 which has seen some countries adopt adapted IMNCI training programs such as distance learning paired with clinical practice.¹¹ In Laos, distance learning was not felt feasible. Furthermore, healthcare workers were trained to practice IMNCI using single-use record forms which both duplicate documentation requirements and run out with no capacity for reprinting in a sustainable way. When this occurs staff trained may no longer effectively apply, or feel they can apply what they have learned in practice.⁴

In 2018, through a process of stakeholder consultation, observation of current training practices and review of training reports it was determined that there was a need to renew and strengthen IMNCI training with respect to teaching pedagogy, building a practice of ongoing supervision to support to health centers and determining whether IMNCI training is impactful at the level of patient–healthcare worker interaction.⁹

This article describes the pilot implementation of redesigned IMNCI training to meet the identified needs in Laos, with a greater emphasis on capacity building among educators, increased integration with parallel programs (e.g., The Pocketbook), utilizing existing workplace tools and establishing relationships for supportive supervision. The pilot program aimed to determine whether the new approach was feasible and acceptable to health workers and if health centers where staff have participated in a new model of IMNCI training showed improvements in pediatric case management.

MATERIALS AND METHODS

Training redesign.

In redesigning IMNCI training approach we acknowledged the need to remove long, facilitator-led information sharing sessions, to use multimedia to support training without adding the need for projectors and computers, and to ensure that skills applied in the initial teaching of IMNCI were applicable to supervision afterward. We developed flexible coaching style modules, which could be applied to a multiday workshop, to consecutive visits during supportive supervision or to one-off short clinical teaching sessions. The coaching modules were based on Merrill’s principles of instructional design¹² whereby learning is promoted through presentation and demonstration of new knowledge, its application by the learning and its integration into real-world contexts.

Teaching activities were structured in accordance with this theory to help participants transition from theoretical knowledge to clinical practice. In sequence, concepts were presented through a question-driven approach (to better target the level of the learner), followed by demonstration (uses model cases or multimedia on tablets), hands-on practice with feedback and finally reinforced, by problem-solving with staff about how learning would be taken back to their clinical setting. In the pilot content focused on danger signs, cough and diarrhea as presenting problems, to ensure the approach worked before adapting all modules. IMNCI facilitators received specific training on this educational framework, the approach to providing participants with constructive feedback and were evaluated for their own skills as educators. Finally, the training model mirrored that developed in Laos for the WHO Pocketbook of Hospital Care for Children.¹³ This meant that clinicians could develop facilitation skills that were transferrable between programs, rather than learning different ways for teaching similar content.

Program implementation.

The intervention is described in Table 1 using the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) framework.¹⁴ Training was implemented in three provinces in Laos, which were supported by the UNICEF country program. Facilitators were trained at provincial and district level at each site by a core group of master facilitators with the aim of developing capacity at the district level and reducing reliance on central support. This ensured those responsible for routine supervision visits had the capacity to upskill health workers. The training schedule (Figure 1) followed a structure of dedicated facilitator training for local staff followed by these new local facilitators delivering training to healthcare workers from local districts in a two-day workshop supported by master facilitators. Newly trained healthcare workers made commitments to practice changes to implement the lessons learned at their health center. This was following by a supervision visit 6–8 weeks later. During the pilot, supervision visits were held in two district health centers per province, each visit facilitated by a “master trainer” and a newly trained local facilitator to practice supportive supervision of health center staff before being expected to provide supervision independently.

Table 1.

Summary of a revised model of IMNCI healthcare worker training in Laos

Feature of the intervention	Description
The key innovation	Flexible delivery of coaching modules relating to care of children presenting with danger signs, cough, or diarrhea as the main problem outlined in IMNCI.
The type of interventions used	Distribution of educational materials (IMNCI chart book). Interactive training workshops comprising of 2 days of facilitator training followed by 3 days of healthcare worker training with a focus on practice and troubleshooting potential challenges in implementing the guidelines at health center level. Healthcare worker training was delivered predominantly in small-group discussion format with frequent (approximately 50% of dedicated training time) opportunity for practical learning (role-play, hands-on practice, group problem-solving). Teaching through discussion allows the facilitators to target teaching to the participants skill level through asking what they already know. Supervision visits to allow for audit and feedback as well as the delivery of further targeted training utilizing the same teaching methodology of discussion, demonstration, and hands-on practice with feedback.
The target group and incentives	Staff working in district health centers in three provinces in Lao PDR. Initial training was held at the provincial hospital to allow for strengthening of the relationship between health center and hospital staff. Travel costs and per-diem for training was provided according to current law in Lao PDR.
The implementers	Lao pediatricians from central and provincial hospitals (considered local opinion leaders). International facilitators comprising Australian-trained medical practitioners who have completed at least 3 years postgraduate training in pediatrics and completed their Royal Australian College of Physician exams. Administrative, financial, and practical support from NGO and Lao Government Curative Child Health Department.
Intervention frequency and intensity	Training of district hospital facilitators followed immediately by new clinical training for health center staff. Supervision visit held approximately 8 weeks after clinical training. Meetings held with district and provincial health officers who in some cases observed training and supervision.
Feedback on performance	Assessment of case management of children from medical records at baseline and after participation of training during the subsequent follow-up visit.

IMNCI = Integrated Management of Neonatal and Childhood Illness; NGO = nongovernment organization

Figure 1.

IMNCI pilot training schedule.

Supervision visits had the objective of assessing successes and challenges for IMNCI implementation following training. Facilitators were trained to explore these issues and deliver targeted training using the flexible training modules if there was a deficiency in knowledge or skill. Facilitators were encouraged to empower healthcare workers to find realistic solutions or safe alternative practices if they faced issues related to a lack of required resources and in doing so, instilling a sense of agency in how the program was implemented in their workplace. At the completion of the visit an action plan was developed by health center staff with key roles and time frames assigned for making the agreed upon changes.

Assessment of outcomes.

Participants completed a pre- and posttraining multiple choice question (MCQ) test assessing their ability to correctly use the IMNCI chart book for given patient scenarios across domains of patient assessment, problem classification, and determining appropriate treatment. This test was designed to be easy to answer with only a small degree of familiarity with the IMNCI chart book. Pre- and posttraining scores were compared using a paired samples t-test. An observed structured clinical examination (OSCE) style clinical scenario where participants were required to demonstrate their skill in the assessment, classification, and treatment of an unwell child utilizing only job aides available to them in their usual clinical practice (IMNCI chart book and clinic case record book) was also administered posttraining.

Participants completed posttraining surveys exploring their satisfaction with the training and confidence in using IMNCI guidelines. Data were analyzed according to the number and percentage of participants responding favorably to each question.

Abstraction of patient data was conducted during health center supervision visits as part of the audit and feedback process for supervision, using a standardized checklist of case management. Case management scores were assigned based on the documentation of key steps of assessment, assigning the correct classification based on signs documented and providing appropriate treatment and follow-up plan.

Data from patients under 5 years of age with cough or diarrhea was recorded from 10 patients at baseline and between 5 and 10 most recent patients. Some centers had insufficient pediatric presentations in the time frame since training to collect 10 records. Case management scores were described by mean scores in pre- and posttraining eras and compared using t-test.

Field notes were documented during training, each supervision visit, and key meetings with the Ministry of Health and other stakeholders such as district health officials outlining key barriers to implementing IMNCI as identified by health center staff as well as proposed solutions. These were reviewed for challenges in relation to IMNCI implementation and grouped into common categories across sites visited.

RESULTS

Fifty-six provincial- and district-level hospital staff were trained as IMNCI facilitators and 43 health center workers (nurses, midwives, and healthcare assistants) were trained across three separate provinces during the pilot. Health center workers were selected for training by the local provincial health office with two training spots offered per district in each of the three provinces. Healthcare workers had a low level of knowledge and skill in using the IMNCI chart book before training (mean 6.9/12, 95% CI 6.2–7.6) compared with posttraining (11.5/12, 95% CI 11.3–11.7, mean difference 4.6, 95% CI 3.9–5.3, P < 0.001). Following a 2-day workshop, health center workers demonstrated competency in the steps of IMNCI assessment and classification of a child when given a clinical stem and audiovisual materials to aid their assessment in a single-station OSCE style test (mean score 13.6/15, 95% CI 13.0–14.1).

All participants participated actively during the training and that the majority were confident in performing individual steps of IMNCI (range 98–100%). 98% (42/43) reported that they now know how to use IMNCI in their practice and all participants (100%) reported that they intended to use IMNCI in their workplace. Qualitative survey responses indicated strong engagement and tangible outcomes.

“Everyone in the group is participating to debate whether danger signs are present or absent.”—Training participant Province 1.

“Now I understand about calculating antibiotics. I never did this before.”—Training participant Training Province 1.

Baseline audit results from supervision at six health centers demonstrated variable practice and change. Posttraining case management scores improved at all but one health center for patients with cough and at all health centers for patients with diarrhea (Figures 2 and 3). The mean case managements scores for all health centers pretraining were 3.0/10 (SD 1.1) for cough and 3.1/10 (SD 1.3) for diarrhea, compared with 5.3/10 (SD 2.1) and 5.9/12 (SD 1.6) posttraining, respectively (P < 0.001).

Figure 2.

Case management scores for children presenting with cough pre and post revised IMNCI training.

Figure 3.

Case management scores for children presenting with diarrhoea pre and post revised IMNCI training.

Recurrent challenges identified by health center staff during training and supervision were a number of essential medicines were lacking (commonly ciprofloxacin, salbutamol metered dose inhaler), IMNCI trained staff encounter difficulties upskilling their colleagues in specific skills (e.g., differentiating between wheeze and stridor) or in meeting standards of documentation because of time constraints or low skill level in this area. When specific skill areas were either reported as or recognized through audit as deficient this allowed the opportunity for further practice during the supervision visit.

DISCUSSION

Our pilot of a redesigned IMNCI training in Lao PDR demonstrates the approach used was acceptable to health workers, increased knowledge and skills in IMNCI and lead to improved case management of pneumonia and diarrhea in target health centers. These results are important as they represent evidence that the IMNCI program, when implemented in an appropriate way, can change healthcare worker action on the ground, at a time when stakeholder interest and support of the program globally is waning.¹⁵

Improvements observed in case management scores were greater than expected given often modest changes with measurements following in-service training of community health workers,¹⁶ and the fact change occurred before the supervision intervention. We had anticipated minimal change after training, and a likelihood that ongoing supervision visits would reinforce practice and be critical to improvement. Ongoing supervision remains critical to make further gains and embed IMNCI in practice.

Our outcomes support literature that describes greater improvement in clinical practice with education techniques that are interactive, allow for practice and feedback, have a high degree of interaction with the educator and utilize multiple teaching techniques including group problem-solving.^16,17 They also align with the literature describing success with a the cascade model of in-service training, commonly adopted in low resource settings because of the ability to train a large number of participants quickly.¹⁸ This literature demonstrates cascade training that can be used to change the action of healthcare worker on the ground when key principles outlined by Hayes¹⁹ are followed. These include developing training that is experiential and reflective, where expertise is diffused throughout the system, and a cross section of stakeholders have been involved. These principles, while represented in the original design of IMNCI have been poorly supported in more didactic local adaptations of the program in Laos as in many settings globally.⁷ Although cascade training models have been criticized for establishing only a one-way transmission of information²⁰ and failing to respond to needs at the grassroots level, the training in this pilot program focused on bidirectional flow of information to ensure that the training remains realistic to the limitations of participants’ work environment and relevant to participants.

The training was highly valued by participants who universally reported that they were actively engaged during the training, found that it helped them build confidence in their skill in practicing IMNCI and felt they would be able to implement the guidelines in their workplace. By explicitly incorporating a step of enquiring about and addressing the barriers to implementation at the health center level the facilitators demonstrated that the experience of healthcare workers is relevant. This process helped find reasonable solutions to bridge the gap between the IMNCI algorithm and what is feasible in the workplace, giving healthcare workers a greater degree of agency over how IMNCI is implemented where they work. Throughout training and the accompanying supervision, participants were quick to point out where a guideline would “fall down” in practice as a result of the structure of their workflow or availability of medicines or equipment. This allowed for facilitators to help them identify an alternative action (such as referring a child to hospital if it was not feasible to treat them at the health center) as well as strategies to rectify the problem locally. In addition, the process of supportive supervision provides a link between the health center and the district hospital, which may allow for the development of mentor–mentee relationships to evolve and act as a link in strengthening the healthcare system.²¹

Structuring the cascade model of training with a greater emphasis on building skill at the provincial and district level is designed for greater sustainability over time. As new district facilitators had the opportunity to deliver training immediately after completing their first training of trainers workshop, it provided an immediate opportunity to practice training delivery with support to gain confidence required to deliver further training independently. Success of this model has potential to save travel costs, time, and loss of staff at central facilities when they are required to travel; however, at this stage, sustainability of the approach and its longer term impact is unknown nor its resource implications at the local level.

Our pilot of a redesigned IMNCI training approach has limitations, including firstly that it is a report from a single country context. It is well recognized that context influences both the approach to and impact of healthcare interventions.²² However, we aim to report on this pilot as an example of a successful reinvigoration of IMNCI in a context with a long history of its use, without evidence of change. Likewise, this pilot focused on case management of diarrhea and pneumonia. This allowed testing of feasibility before expanding to other content, but a consequence was delivery of shorter, targeted training and may be one of the reasons change in care was demonstrated—as health workers were able to focus on change in particular practices. Although this is not representative of the entire IMNCI content, the approach provides a thorough foundation for the use of the IMNCI chart book in clinical practice, onto which other knowledge and content can be built later, ideally through regular supervision visits. It is anticipated this will be done through the newly created, motivated local group of facilitators with a now strong understanding of IMNCI—but it remains to be seen if funding and health systems support this to happen.

Our measurement of change in this pilot was based on quality improvement principles, that repeated measurement of small sample time can demonstrate trends. We did not anticipate demonstrating change on the first supervision visit, and ongoing measurement over time will make this approach more robust. Our approach also recognized the relatively low numbers of patients presenting at health centers in Laos, and the need to use data that was feasible to incorporate in regular supervision.

Our outcomes highlight that in-service education programs that keep adult learning principles at their core can result in improvements in healthcare worker action. Any health worker training should be interactive and factor in the limitations of the work environment to close the gap between “what I do in training” and “what I do at work.” There is now a need to determine the long-term sustainability and the impact of the approach including supportive supervision, how to effectively incorporate expanded content, and to understand how the model could be scaled.