Training evaluation: a case study of training Iranian health managers

<p>Abstract</p> <p>Background</p> <p>The Ministry of Health and Medical Education in the Islamic Republic of Iran has undertaken a reform of its health system, in which-lower level managers are given new roles and responsibilities in a decentralized system. To support these efforts, a United Kingdom-based university was contracted by the World Health Organization to design a series of courses for health managers and trainers. This process was also intended to develop the capacity of the National Public Health Management Centre in Tabriz, Iran, to enable it to organize relevant short courses in health management on a continuing basis. A total of seven short training courses were implemented, three in the United Kingdom and four in Tabriz, with 35 participants. A detailed evaluation of the courses was undertaken to guide future development of the training programmes.</p> <p>Methods</p> <p>The Kirkpatrick framework for evaluation of training was used to measure participants' reactions, learning, application to the job, and to a lesser extent, organizational impact. Particular emphasis was put on application of learning to the participants' job. A structured questionnaire was administered to 23 participants, out of 35, between one and 13 months after they had attended the courses. Respondents, like the training course participants, were predominantly from provincial universities, with both health system and academic responsibilities. Interviews with key informants and ex-trainees provided supplemental information, especially on organizational impact.</p> <p>Results</p> <p>Participants' preferred interactive methods for learning about health planning and management. They found the course content to be relevant, but with an overemphasis on theory compared to practical, locally-specific information. In terms of application of learning to their jobs, participants found specific information and skills to be most useful, such as health systems research and group work/problem solving. The least useful areas were those that dealt with training and leadership. Participants reported little difficulty in applying learning deemed "useful", and had applied it often. In general, a learning area was used less when it was found difficult to apply, with a few exceptions, such as problem-solving. Four fifths of respondents claimed they could perform their jobs better because of new skills and more in-depth understanding of health systems, and one third had been asked to train their colleagues, indicating a potential for impact on their organization. Interviews with key informants indicated that job performance of trainees had improved.</p> <p>Conclusion</p> <p>The health management training programmes in Iran, and the external university involved in capacity building, benefited from following basic principles of good training practice, which incorporated needs assessment, selection of participants and definition of appropriate learning outcomes, course content and methods, along with focused evaluation. Contracts for external assistance should include specific mention of capacity building, and allow for the collaborative development of courses and of evaluation plans, in order to build capacity of local partners throughout the training cycle. This would also help to develop training content that uses material from local health management situations to demonstrate key theories and develop locally required skills. Training evaluations should as a minimum assess participants' reactions and learning for every course. Communication of evaluation results should be designed to ensure that data informs training activities, as well as the health and human resources managers who are investing in the development of their staff.</p

An evaluation of growth monitoring in Zaire

Growth monitoring has become a major component of most child health programmes in developing countries over the past two decades. The rationale for this activity is discussed and examined critically in the light of the evidence from previous studies and from a detailed evaluation of three child health care programmes in rural Zaire which included growth monitoring. The monthly sessions to which mothers brought their children were observed, the health workers were interviewed, and information was obtained on programme costs, supervision, and health records in all three programmes. A survey of the knowledge and practices of 547 mothers of children under five years of age was carried out in one programme's catchment population. A total of 497 consultations were observed in the three programmes as part of the evaluation. The consultations lasted between 30 seconds and five minutes each, with a mean of two minutes. Mothers and children spent three to eight hours at the clinic in order to receive these brief consultations, ten minutes of group health education, and if necessary, immunizations. Whilst staff measured and recorded weights accurately, they failed to take any specific actions in one-third of children who had growth faltering. Similarly, no counselling was given to one-third of mothers whose children were ill and/or had growth faltering, called "at-risk" children. Generally, the quality of advice and referral for illness was more satisfactory than the nutritional advice given mothers, which consisted of brief, standard directives. The at-risk children did not always receive special consultations by better-qualified staff. A household interview survey of 547 mothers of children under five assessed their understanding of the growth charts and their knowledge and reported practices with regard to child feeding and diarrhoea. Results showed that knowledge and practices improved with increased attendance at growth monitoring sessions, after controlling for the mother's educational level, tribe, socio-economic level and parity. Since nearly two-thirds of children attending the sessions were classified as at-risk, the value of individual screening by weighing is questionable. Not all at-risk children received interventions; of those who did, the quality of the interventions was frequently inadequate. Policy and programme recommendations for growth monitoring in child health programmes are described, and research needs identified

The community health representative in Alberta : a program evaluation

The Indians of Alberta sustain levels of health and well-being well below that of the average Canadian. Recognizing that the traditional health care system required modification for the special needs of Indians, Medical Services Branch of the Department of National Health and Welfare set up their first training program in 1962 to prepare Indian public health auxiliary workers, called Community Health Representatives. The hope was that the program would, among other things, allow Indians to be more involved in their own health care, extend the coverage of the health services and act as a vehicle to further community development of Indian reserves. To evaluate this program, the general objectives of the program and the job description of the CHR's were used to derive short-term objectives which were examined on visits to reserves. Quantitative data were not available for assessing the achievement of objectives, but interviews and observations allowed a qualitative assessment of the program's effectiveness. The activities of CHR's and Medical Services in this program were examined in the context of their "environment" - the geographic, biological, psychological, sociological and anthropological factors which are both the cause and the effect of the health status of. a people. From this very broad standpoint, a critique of the effectiveness, and the policy and direction of the program was offered. The CHR's were found to be functioning in varying modes, with varying levels of effectiveness. Most carried out traditional public health nursing, acting mainly as assistants to the nurses. A few had a more political bent and were involved with committee work, the Band Council and general development on the reserve. Health services may he extended by this program, but the goals of community development and community involvement in health care are achieved to a markedly less extent. Several situational and policy variables which may account for this are put forward. The program is seen to be too small and too isolated from wider events in the political and health spheres to have had any great impact on Indian development and health. The resources available to the CHR program from within Medical Services have been scant, and the program has developed few relationships with outside agencies, especially a similar provincial program. The political and social isolation of Indians in Canada is echoed by the isolation of this program within the Department of National Health and Welfare and the province. The program's potential of improving Indian health, of acting as a lever to general development, of encouraging Indians to train and work in the health field to eventually have Indians in control of their health service, has not nearly been met. The political uncertainties surrounding Indian affairs make it difficult to foresee the results of any decisions. However, if the Indian health service and this program eventually become the responsibility of the province, the scope and circumstances under which it will be operating will broaden. The advantages of having the large provincial service's resources available to the program will be great, and the possibility of closer integration with Indian and regional development will arise. The most precious asset of the program, its flexibility, its ability to adapt to individual communities, must be carefully maintained. Thinking about these potentials and preparation for such changes should start now.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Is growth monitoring worthwhile? An evaluation of its use in three child health programmes in Zaire

Growth monitoring has become a major component of many child health programmes in developing countries over the past two decades. Little research has been carried out on the separate contribution of growth monitoring to the effectiveness of child health programmes, and discussion on the subject frequently take on an exhortative rather than a scientific character. This paper reports some of the results of an evaluation of three child health programmes in rural Zaire which used growth monitoring as a screening tool for targeting health and nutrition interventions. The monthly sessions to which mothers brought their children were observed, the health workers interviewed, and information obtained on the supervision system in the programmes, in order to determine wether the health workers accurately identified at-risk children and provided appropriate interventions through the use of growth monitoring information. Health staff were observed weighing and consulting a total of 506 mothers and children. Whilst they measured and recorded weights accurately, they did not carry out any further investigation in one-third of children who had experienced growth faltering. Similarly, no counselling was given to one-third of mothers whose children were ill and/or had growth faltering, called collectively 'at-risk children'. Generally, the quality of advice and referral for illness was more satisfactory than the nutritional advice given to mothers, which consisted of brief, standard directives. The value of individual screening by weighing is questioned, since attendance was infrequent and non-representative, many mothers identified their children as ill and therefore at-risk even before they were weighed, and since nearly two-thirds of children attending the sessions were classified as at-risk. The theoretical gain in health service efficiency by targeting was largely lost by the staff-time required to weigh and record the weights of individual children, and the fact that the information that a child had growth faltering was frequently not acted upon. The programmes did not exploit the potential of growth monitoring as an educational and motivational tool to promote action by mothers and communities to improve their children's health. The use of growth monitoring did not appear to be an important factor in the overall quality of care within these three programmes. The disappointing results of this evaluation, which have been mirrored in other recent reports, and a review of the theoretical grounds for growth monitoring, have led the authors to conclude that the case for including growth monitoring in child health programmes remains unproven either on theoretical grounds or in practice. There is a critical need for further research into the cost-effectiveness of growth monitoring, but the introduction of growth monitoring into future child health programmes appears difficult to justify at present.growth monitoring child health programmes evaluation

Emergency obstetric referral in rural Sierra Leone: what can motorbike ambulances contribute? A mixed-methods study.

Giving birth remains a dangerous endeavour for many of the world's women. Progress to improve this has been slow in sub-Saharan Africa. The second delay, where transport infrastructure is key in allowing a woman to reach care, has been a relatively neglected field of study. Six eRanger motorbike ambulances, specifically engineered for use on poor roads in resource-poor situations were provided in 2006 as part of an emergency referral system in rural Sierra Leone. The aim of this study was to evaluate the implementation of this referral system in terms of its use, acceptability and accessibility. Data were collected from usage records, and a series of semi-structured interviews and focus groups conducted to provide deeper understanding of the service. A total of 130 records of patients being transported to a health facility were found, 1/3 of which were for obstetric cases. The ambulance is being used regularly to transport patients to a health care facility. It is well known to the communities, is acceptable and accessible, and is valued by those it serves. District-wide traditional birth attendant training and the sensitisation activities provided a foundation for the introduction of the ambulance service, creating a high level of awareness of the service and its importance, particularly for women in labour. Motorbike ambulances are suited to remote areas and can function on poor roads inaccessible to other vehicles

Health policy processes in Vietnam: A comparison of three maternal health case studies

Objectives To describe and analyse the policy processes related to maternal health in Vietnam.Methods A multi-method, retrospective comparative study of three case studies of maternal health policy processes-skilled birth attendance, adolescent reproductive health and domestic violence. It drew on primary qualitative data and secondary data. The underpinning conceptual framework of the study with key elements of policy processes is described.Results The study identified significant differences between the policy processes related to the different case studies. Various factors affect these processes. Critical amongst these are the nature of the policy, the involvement of different actors and the wider context both nationally and internationally. The changing national context is opening up increasing opportunities for civil society to interact with policy processes.Conclusions Understanding the nature of policy processes is critical to strengthen them, particularly in a changing environment. There is potential for a review of government policy processes which were developed in the period prior to Doi Moi to reflect the changing composition of civil society.Health policy Reproductive health Maternal health Adolescent reproductive health Domestic violence

Health policy processes in maternal health: A comparison of Vietnam, India and China

This article reports on a comparative analysis to assess and explain the strengths and weaknesses of policy processes based on 9 case-studies of maternal health in Vietnam, India and China. Policy processes are often slow, inadequately coordinated and opaque to outsiders. Use of evidence is variable and, in particular, could be more actively used to assess different policy options. Whilst an increasing range of actors are involved, there is scope for further opening up of the policy processes. This is likely, if appropriately managed with due regard to issues such as accountability of advocacy organisations, to lead to stronger policy development and greater subsequent ownership; it may however be a more messy process to co-ordinate. Coordination is critical where policy issues span conventional sectoral boundaries, but is also essential to ensure development of policy considers critical health system and resource issues. This, and other features related to the nature of a specific policy issue, suggests the need both to adapt processes for each particular policy issue and to monitor the progress of the policy processes themselves. The article concludes with specific questions to be considered by actors keen to enhance policy processes.Health policy processes Maternal health Actors Evidence Context Vietnam India China