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An assessment of a 'training-of-trainers programme for clinic committees' in a South African district: a qualitative exploratory study.

ABSTRACT: BACKGROUND:In South Africa (SA), clinics and community health centres are the predominant primary level health care facilities in the public health sector. As part of legislated health governance requirements, clinic committees (referring to those for clinics and community health centres) were established to provide management oversight and bring to bear the perspectives and participation of communities at Primary Health Care (PHC) facilities. Clinic committees need training in order to better understand their roles. Facilitators in a district of SA were trained through a designated programme, called the 'PHC Facility Governance Structures Trainer-of-Facilitator (ToF) Learning Programme', in preparation for the training of clinic committees. This paper explores how the programme had evolved and was experienced by the trained facilitators, in a district in SA. METHODS:We employed a retrospective qualitative case study design, guided by the Illuminative Evaluation Framework, with the training programme in the selected district as the case. The study assessed whether the intended aims of the training programme were clearly conveyed by the trainers, and how participants understood and subsequently conveyed the training programme intentions to the clinic committees. Key informant interviews and focus group discussions were conducted with trainers and managers, complemented by a review of relevant policy and legislative documents, and published literature. Study participants were purposively selected based on their involvement in the development, facilitation or training of the programme. Thirteen individuals participated in the study, and 23 (national, provincial and partner) documents were reviewed. RESULTS:Despite the different perceptions and understandings of the ToF Learning Programme, its overall aims were achieved. Trainers' capacity was strengthened and clinic committees were trained accordingly. The training programme holds promise for possible national scale-up. The high quality of the interactive posters can be considered equally valuable as a training tool as the training manuals. CONCLUSIONS:Trainers' capacity was strengthened and clinic committees were trained accordingly, despite deviations in implementation of the original training approach and plan.

SUBMITTER: Esau N

PROVIDER: S-EPMC7702689 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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An assessment of a 'training-of-trainers programme for clinic committees' in a South African district: a qualitative exploratory study.

Esau Natasha N English René R Shung-King Maylene M

BMC health services research 20201130 1

<h4>Background</h4>In South Africa (SA), clinics and community health centres are the predominant primary level health care facilities in the public health sector. As part of legislated health governance requirements, clinic committees (referring to those for clinics and community health centres) were established to provide management oversight and bring to bear the perspectives and participation of communities at Primary Health Care (PHC) facilities. Clinic committees need training in order to ...[more]

PMID: 33256722

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Project description:BackgroundThe complicity of the South African health sector in apartheid and the international relevance of human rights as a professional obligation prompted moves to include human rights competencies in the curricula of health professionals in South Africa. A Train-the-Trainers course in Health and Human Rights was established in 1998 to equip faculty members from health sciences institutions nationwide with the necessary skills, attitudes and knowledge to teach human rights to their students. This study followed up participants to determine the extent of curriculum implementation, support needed as well as barriers encountered in integrating human rights into health sciences teaching and learning.MethodsA survey including both quantitative and qualitative components was distributed in 2007 to past course participants from 1998-2006 via telephone, fax and electronic communication.ResultsOut of 162 past participants, 46 (28%) completed the survey, the majority of whom were still employed in academic settings (67%). Twenty-two respondents (48%) implemented a total of 33 formal human rights courses into the curricula at their institutions. Respondents were nine times more likely (relative risk 9.26; 95% CI 5.14-16.66) to implement human rights education after completing the training. Seventy-two extracurricular activities were offered by 21 respondents, many of whom had successfully implemented formal curricula. Enabling factors for implementation included: prior teaching experience in human rights, general institutional support and the presence of allies - most commonly coworkers as well as deans. Frequently cited barriers to implementation included: budget restrictions, time constraints and perceived apathy of colleagues or students. Overall, respondents noted personal enrichment and optimism in teaching human rights.ConclusionThis Train-the-Trainer course provides the historical context, educational tools, and collective motivation to incorporate human rights educational initiatives at health sciences institutions. Increased implementation of human rights instruction, both formally and extracurricularly, has demonstrated the training's significance not only within academic institutions but more broadly across the health sector. Coworkers are vital allies in teaching human rights to health sciences students, helping to alleviate institutional barriers. Training fellow staff members and those in key leadership roles is noted as vital to the sustainability of human rights education.

Project description:ObjectivesTrust plays an important role in workplace-based postgraduate medical education programmes. Trainers must trust their trainees for granting them greater independence. Trainees must trust their trainer for a safe learning environment. As trainers' and trainees' trust in each other plays an important role in trainee learning and development, the authors aimed to explore the development of the mutual trust relationship between trainers and trainees.SettingThis study was performed in a general practice training department in the Netherlands.ParticipantsAll trainers and trainees of the general practice training department were invited to participate. Fifteen trainers and 34 trainees, voluntarily participated in focus group discussions.Outcome measuresThe authors aimed to gain insight in the factors involved in the development of the mutual trust relationship between trainers and trainees, in order to be able to create a model for the development of a mutual trust relationship between trainers and trainees. The risk-based view of trust was adopted as leading conceptual framework.ResultsIn the first stage of trust development, trainers and trainees develop basic trust in each other. Basic trust forms the foundation of the trust relationship. In the second stage, trainers develop trust in trainees taking into account trainees' working and learning performance, and the context in which the work is performed. Trainees trust their trainer based on the trainer'savailability and accessibility and the personal relationship between the trainee and their trainer. Trainee self-confidence modifies the development of a trust relationship.ConclusionThe development of a mutual trust relationship between trainers and trainees is a complex process that involves various stages, goals, factors and interactive aspects. As the mutual trust relationship influences the learning environment for trainees, greater emphasis on the mutual trust relationship may improve learning outcomes. Further research may explore the effect of long-term and short-term educational relationships on the trust relationship between trainers and trainees.

Project description:South Africa has implemented a community-based HIV programme (CBHP) in its primary healthcare (PHC) re-engineering strategy that aims to improve public healthcare delivery. This CBHP is delivered by ward-based outreach teams (WBOTs); provision of community HIV services comprises an important component of this programme. We conducted an exploratory study to determine the facilitators and barriers to successful implementation of this CBHP in rural Mopani District, South Africa. Focus group discussions were conducted with the community health workers (CHWs) and PHC nurses; participant interviews were conducted with community members who access these health services, community leaders, and social workers. We conducted a thematic content analysis and based on the key themes reported, we identified the Consolidated Framework for Implementation Research, consisting of five domains, as the most appropriate model to interpret our findings. First, in terms of intervention characteristics, community members generally valued the HIV services provided, but the variable needs impacted on programme implementation. Outer setting challenges include inability to meet the need of patients as a result of stigma, non-disclosure of HIV status and social factors. In terms of the inner setting, CHWs were grateful for the equipment and training received but expressed the need for better support of management and the provision of additional resources. With regard to characteristics of the implementers, the CHWs expressed the desire for further training despite reporting having sufficient knowledge to conduct their HIV work. Finally, in terms of the implementation process, the importance of relationship building between CHWs and community members was emphasised. In conclusion, these data underline the positive receipt and potential of the CBHP in this rural district and identify areas to further strengthen the programme. The success and sustainability of the CBHP requires ongoing commitment of resources, training, supervision, and organisational support in order to operate effectively and efficiently.

Project description:Background In order to develop a district child and adolescent mental health (CAMH) plan, it is vital to engage with a range of stakeholders involved in providing CAMH services, given the complexities associated with delivering such services. Hence this study sought to explore multisectoral dynamics in providing CAMH care in one resource-constrained South African district as a case study, towards informing the development of a model for district mental health plan and generating lessons for mental health systems strengthening to support CAMH services using the Health Systems Dynamics (HSD) framework. HSD provides a suitable structure for analysing interactions between different elements within the health system and other sectors. Methods Purposive sampling of 60 key informants was conducted to obtain an in-depth understanding of various stakeholders' experiences and perceptions of the available CAMH services in the district. The participants include stakeholders from the Departments of Health (DoH), Basic Education (DBE), community-based/non-governmental organizations and caregivers of children receiving CAMH care. The data was categorized according to the elements of the HSD framework. Results The HSD framework helped in identifying the components of the health systems that are necessary for CAMH service delivery. At a district level, the shortage of human resources, un-coordinated CAMH management system, lack of intersectoral collaboration and the low priority given to the CAMH system negatively impacts on the service providers' experiences of providing CAMH services. Services users' experiences of access to available CAMH services was negatively impacted by financial restrictions, low mental health literacy and stigmatization. Nevertheless, the study participants perceived the available CAMH specialists to be competent and dedicated to delivering quality services but will benefit from systems strengthening initiatives that can expand the workforce and equip non-specialists with the required skills, resources and adequate coordination. Conclusions The need to develop the capacity of all the involved stakeholders in relation to CAMH services was imperative in the district. The need to create a mental health outreach team and equip teachers and caregivers with skills required to promote mental wellbeing, promptly identify CAMH conditions, refer appropriately and adhere to a management regimen was emphasized.

Project description:BackgroundAs part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system.MethodsWe conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs.ResultsThe new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting.ConclusionDistrict managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.

Project description:BackgroundWhile integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs.MethodsCHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making.ResultsCHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC.ConclusionsLack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.

Project description:BackgroundKey to effective supportive supervision, and ultimately performance of community health workers (CHWs), is the nature of relationships in the formal health system at the coal face of programmes. The central character and defining feature of effective relationships, in turn, is the ability to engender trust. This study describes factors associated with workplace and interpersonal trust, the relationship between the two sets of trust factors and how this shaped perceived performance of CHWs in ward-based outreach teams (WBOTs) in a rural South African district.MethodsIn the context of a wider study of supportive supervision of CHWs, factors recognised to be associated with trust in the literature were studied qualitatively in Ngaka Modiri Molema district, North West Province. Focus group discussions (FGDs) and individual interviews were conducted by the first author with CHWs (23), team leaders (12), facility managers (10) and middle managers (5). Interviews were recorded, translated and transcribed. Perceptions of trust factors associated with workplace and interpersonal trust were analysed thematically.ResultsThe interviews revealed a climate of considerable workplace mistrust due to the perceived abandonment of the WBOTs programme by managers at all levels, and this affected support and supervision of WBOTs. However, there was a degree of variability and discretion in expressions of interpersonal trust at the coal face, leading to different perceptions of the competence and functionality of the WBOTs. Mistrust in the workplace and poor interpersonal relationships translated into low confidence in the ability of CHWs, which in turn compromised the performance of these teams.ConclusionThe study contributes empirical evidence on how workplace trust factors impact on interpersonal trust factors and the possible implications of both sets of trust factors on perceived performance of CHWs. Wider trust in the health system have a significant bearing on interpersonal trust between CHWs and other players in the primary healthcare (PHC) system.

Project description:BackgroundA pragmatic three-tiered approach to monitor the world's largest antiretroviral treatment (ART) programme was adopted by the South African National Department of Health in 2010. With the rapid expansion of the programme, the limitations of the paper-based register (tier 1) were the catalyst for implementation of the stand-alone electronic register (tier 2), which offers simple digitisation of the paper-based register. This article engages with theory on implementation to identify and contextualise enabling and constraining factors for implementation of the electronic register, to describe experiences and use of the register, and to make recommendations for implementation in similar settings where standardisation of ART monitoring and evaluation has not been achieved.MethodsWe conducted a qualitative evaluation of the roll-out of the register. This comprised twenty in-depth interviews with a diverse sample of stakeholders at facility, sub-district, and district levels of the health system. Facility-level participants were selected across five sub-districts, including one facility per sub-district. Responses were coded and analysed using a thematic approach. An implementation science framework guided interpretation of the data.Results & discussionWe identified the following seven themes: 1) ease of implementation, 2) perceived value of an electronic M&E system, 3) importance of stakeholder engagement, 4) influence of a data champion, 5) operational and logistical factors, 6) workload and role clarity, and 7) importance of integrating the electronic register with routine facility monitoring and evaluation. Interpreting our findings through an implementation theory enabled us to construct the scaffolding for implementation across the five facility-settings. This approach illustrated that implementation was not a linear process but occurred at two nodes: at the adoption of the register for roll-out, and at implementation at facility-level.ConclusionIn this study we found that relative advantage of an intervention and stakeholder engagement are critical to implementation. We suggest that without these aspects of implementation, formative and summative outcomes of implementation at both the adoption and coalface stages of implementation would be negatively affected.

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An assessment of a 'training-of-trainers programme for clinic committees' in a South African district: a qualitative exploratory study.

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An assessment of a 'training-of-trainers programme for clinic committees' in a South African district: a qualitative exploratory study.

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