Over the last 20 years, tremendous advances have been made in the field of adult learning. These advances could have a transformative effect on training programs, making them more targeted, engaging, and impactful. As a global community, we invest significant resources in training the health workforce in immunization, and this provides an opportunity to make that training more efficient and more effective.
In November 2015, the Bill & Melinda Gates Foundation hosted Teach to Reach: Innovative Methods for Immunization Training – a summit bringing together learning specialists, development partners, and immunization professionals to share best practices, explore advances in learning science and instructional design, and engage in a conversation about how best to use new strategies and tools to improve immunization training. Coordinated by the instructional design firm, Bull City Learning, the meeting gathered over 70 professionals in Seattle to design their vision of what is possible for the future. Participants from Nigeria at the summit included Dr. Bassey Okposen (NPHCDA), Dr. Andrew Etsano (NPHCDA), Dr. Obi Emelife (NPHCDA), Dr. Daniel Ali (WHO), Dr. Onimisi (WHO), Dr. John Agbor (UNICEF), Dr. Odoh (UNICEF) and Mrs. Abiola Ojumu (Clinton Health Access Initiative, CHAI).
Now, five months after the summit, we checked in with a few of the participants from Nigeria to see how they have made progress and incorporated lessons learned in their work. Dr. Bassey Okposen, has served as the Head of Routine Immunization and Essential Services at the National Primary Health Care Development Agency (NPHCDA) in Nigeria since 2013. He also chairs the Routine Immunization Working Group (RIWG) – a consortium of all partners working on immunization systems in the country. Dr. Bassey and his team are working to revitalize the national immunization training task team and to create a consolidated immunization training plan for the country.
Among the many partners supporting Dr. Bassey are Abiola Ojumu and Abisola Olaniyan from Clinton Health Access Initiative (CHAI), who work on system strengthening efforts, particularly focused on improving the capacity of health workers to plan and manage services. Abiola and Abisola shared with us how they worked with Lagos State Government to make a recent immunization training more practical, hands-on, and engaging without much additional expense. Dr. Bassey, Abiola and Abisola also shared their vision for the future of immunization training in Nigeria.
Current challenges in immunization training
When we spoke with Dr. Bassey, Abiola and Abisola, we discussed the challenges of finding an effective means of communicating from national to peripheral levels within the health system when preparing for a new vaccine introduction, an immunization campaign, or a new policy for instance. Some of the challenges currently being faced in immunization training in Nigeria include the following:
Difficulty reaching all health facilities – where actions are taking place – in a timely manner given the size of the country (around 180 million people);
- High cost of completing a cascaded training from the national to the lower levels;
- Weak coordination of training activities due to lack of a coordinated multi-year training plan, which can result in ineffective utilization of limited available resources for training;
- High participant to facilitator ratio – usually about 50 participants to only 3 facilitators – which does not allow for individualized attention;
- Potential for information overload given the largely theoretical, didactic training style with little emphasis on practical learning – making training an event rather than a learning process;
- Potential to create a monopoly of knowledge for those who were able to attend training because a plan to reach those unable to attend does not exist;
- Staff attrition and transfers could result in people who have been trained not being available to provide services after training; and
- Inadequate post-training supportive supervision, mentorship and assessment of training uptake.
Doing things differently after the Teach to Reach Summit
Dr. Bassey, along with the co-chairs of the national immunization training task team: Dr. Emelife, a Deputy Director within NPHCDA, and Dr. Onimisi, immunization training focal point from WHO, have been working to redefine the National Training Working Group (responsible for the coordination and management of training across health in Nigeria). Their focus is on ensuring adequate time to plan training, as well as implementing innovative ideas to improve the quality of training. These include: employing ‘trained’ trainers; focusing on the quality of training at each level (including those that do not have access to technology) by using a standardized manual that can be referenced even after training, providing wrap-around support to staff; and involving supervisors in training so that they will be able to assess uptake of information beyond training when they provide supportive supervision and on-the-job support.
Abiola and Abisola worked with the Lagos State Government and other immunization stakeholders in Lagos state to improve the delivery of a Vaccine Management and Immunization Basics training for 223 private sector healthcare workers. They started by revising the existing training agenda to identify subjects that could be delivered practically rather than theoretically – for example, using life sized dolls to practice injection techniques. They planned for the additional resources that would be needed to implement these practical, hands-on sessions but only required about $665 USD in additional expenses (less than 2% more than the entire training budget).
They recruited additional facilitators (5 facilitators per 50 participants) and reorganized the training venue to allow for practical learning tables where healthcare workers could participate in hands-on practice of some of the things that were taught in the training. Participants got the opportunity to try their hands on assembling a safety box, conducting an actual shake test (to check if freeze-sensitive vaccines might have been frozen at one time, destroying their potency), packing vaccines into cold boxes and vaccine carriers, and practicing safe injection techniques for different ways of giving an injectable vaccines. To address the challenge in cascading the knowledge learned in training to staff who could not participate, key take-away messages from the training were developed and reviewed by the facilitators with all participants. These key take-away points were printed and participants were each given a copy to help guide conversations with their colleagues about what they learned at the training.
Reaction to the changes
The reaction to the changes in Nigeria has been very positive. Dr. Bassey mentioned that the partners are happy because they are all working together toward the same goal. And it was Abiola and Abisola’s experience that the new methods of making training more practical and hands-on in Lagos were well received by Lagos State Government officials and partners because they recognized the need to improve participants’ understanding and knowledge retention in training.
Hopes for the future of immunization training in Nigeria
We asked Dr. Bassey, Abiola, and Abisola what their hopes for the future of immunization training in Nigeria were, and their responses were simple yet profound. Dr. Bassey has many hopes for immunization training in Nigeria – that planning is done well; training is participatory; all partners are using the same manual so information is consistent across training; and that training is provided to those most in need first. Dr. Bassey mentioned how much he appreciates the support from partners, and that he has been inspired to think outside of the box about how to do things differently. Abiola and Abisola see a huge window of opportunity to transform how immunization trainings are conducted in Nigeria in coordination with the reactivated National Training Working Group. Ongoing efforts by partners to pilot and implement new training approaches will also provide examples of different models to consider for scale up for different cadres of healthcare workers.
As Nigeria works to systematically improve immunization training, many partners are supporting Dr. Bassey and his team. Examples include UNICEF exploring digitizing some key immunization modules for adaptive learning, and Johns Hopkins University (through International Vaccine Access Center, IVAC) strengthening national and state coordination of training and the utilization of adult learning methodologies. For more information about ongoing efforts in Nigeria to build stronger training approaches in immunization, please contact Dr. Bassey and his team.
Innovation in the area of training and skills transfer is critical to achieving our immunization goals. We are enthusiastic about the efforts of our Nigerian partners, and look forward to continuing momentum in the future.