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2001 contents page
Training vaccinators in a time of change
Scott Wittet describes one nongovernmental
organizations experience of training with partners in countries
agrees that effective staff training is crucial for quality immunization
services. It seems obvious, especially now when many countries are
introducing new vaccines, new injection technologies, and new policies.
Why is it then that training activities have been neglected, sometimes
for many years? Why is training so often given short shrift
insufficient staff allocation, insufficient budget, and insufficient
At a recent meeting in Manila of the
Alliances Western Pacific Regional Working Group for Immunization,
delegations from three countries approved for support from the Vaccine
Fund were asked to say how the RWG could assist them. One of the
first requests from all three delegations was: "Give us help with
training programmes." As one observer put it: "There is a flood
of autodisable syringes and vaccine vials bearing down on these
countries they have to tell their people how to deal with
it. The countries are grateful for these needed supplies, and ready
to strengthen services, but there is a lot of anxiety as well."
The Gates Childrens Vaccine Program
at PATH is collaborating on training initiatives with Ministries
of Health, NGOs, and other GAVI partners in India, Cambodia, and
several other Asian and African countries. This "note from the field"
shares recent experiences with the development and implementation
of training programmes during this time of change. We hope that
lessons we have learned will be useful to colleagues in other parts
of the world.
First, find out what staff know
and what they need
Every country situation is different
and requires careful strategic planning to meet local needs and
to be successful within the local environment. Good planning begins
with good information, especially information from those who will
be trained. We have found that qualitative rapid assessments of
staff needs are a cost-effective way to get a sense of gaps in knowledge
and skill. Such methods provide a different type of data than closed-ended
questionnaires (the latter can be administered and analysed on a
larger scale, for quantitative information, but offer only a choice
between existing, set responses, rather than an opportunity to express
any original viewpoint). Typically, qualitative data are useful
for the design of training and other initiatives aimed at changing
behaviour. What is more, such methods are cheaper and generate information
much more quickly than a large-scale survey. The rapid assessment
reports referenced1 include sample discussion
guides for focus groups and individual interviews, along with details
about audience research methods that proved effective in those countries.
Qualitative data also are helpful for
designing questionnaires for quantitative surveys, if desired. Such
surveys are particularly useful for programme evaluation.
Safety, service quality, and coverage
suffer without well-trained staff
When we take the time to listen
to service providers, they often complain that they have not received
immunization refresher training in many years. (The main exception
is the good work done training people to assist with polio campaigns.)
Recent rapid assessments of service providers knowledge and
attitudes in India and Nepal reveal a number of common weaknesses
that appear to be related to inadequate training and education.
For example, several providers report hearing individual accounts
of children dying within hours of receiving reconstituted measles
vaccine that had been allowed to sit overnight. Whatever the reasons
for the reported deaths, the staff assumed that the vaccine had
become toxic. As a result, respondents reported, many field workers
in the area refused to continue providing measles vaccine without
a doctor being present, and measles coverage declined rapidly over
the following two years.
The findings revealed two problems:
first, that some vaccinators appear to have received no training
in the safe use of measles vaccine and the prompt disposal of reconstituted
unused vaccine; second, that staff were not supported in the thorough
recording and analysis of reported adverse events linked to vaccination.
Thus, even though the deaths could have been isolated events that
had no causal relationship with the improper delivery of the vaccine,
staff became wary of using a safe vaccine and children were left
We were further alarmed by the fact
that many of the health workers and managers did not regard measles
as a killer disease and did not give measles vaccination high priority.
This is a failure of training and advocacy within the system, and
helps to explain high drop-out rates.
The assessment of health workers
beliefs and knowledge revealed other common concerns too. Asked
what they knew about hepatitis B and whether they supported introduction
of the vaccine, most health workers were cautiously positive, but
emphasized that training should be given high priority.
They also complained that they lack
the training, and often the time, to mobilize community groups in
support of routine immunization efforts a strategy which
would help boost coverage and save many young lives.
When we first began discussing training
strategies with our Ministry partners in one Asian country, we assumed
that the curriculum would focus primarily on new services and procedures.
However, our colleagues in that country felt strongly that a more
comprehensive approach should be taken, so the team decided that
each vaccinator would receive a full two-day refresher training.
The course would communicate information on hepatitis B vaccine
and auto-disable (AD) syringes. It would also ensure that vaccinators
injection skills were excellent, and that they would be able to
conduct more efficient and effective outreach. In addition, the
course would ensure that staff were equipped with improved interpersonal
communication and social mobilization abilities.
High-quality, effective training
takes time to design, implement, and evaluate
Countries have applied for, and received,
vaccines from the GAVI partners and the Vaccine Fund at unprecedented
speed. This has created immense challenges and very tight
timeframes. Maximizing the effectiveness of training programmes
requires a multi-step process, something like that shown in Box
1: Successful training: some
suggested ingredients and timelines
- Understand your various training audiences
and their needs--trainees might include vaccinators (including
private providers, paediatricians, and hospital staff),
their managers, cold chain personnel, and stock managers,
- Develop a comprehensive training strategy
for each cadre of trainee, taking into account constraints
such as staff availability and training budget;
- Identify and recruit the team needed to
carry out the strategy;
- Design and pre-test handouts, job aids,
exercises, and visual aids to be used during training courses;
- Organize the courses and make certain that
the right staff are invited and attend (this requires the
support of all programme and clinic managers an advocacy
initiative in its own right2;
- Implement strategy and evaluate training
- Revise future courses based on your experience
and evaluation results.
A reasonable timeline for steps
one to five is six to nine months, then add the time actually
needed for training, depending on the total number of trainees
and other factors. Plan to evaluate training impact a month
or so after the sessions. In reality, due to a dearth of time,
budget, staff, or political will, sometimes the process outlined
above is abbreviated, or adapted for the local situation
Training often exposes policy gaps
and forces decisions
One of the reasons that the design of
training programmes takes so long is the fact that the documentation
of procedures (i.e. writing the training manual) requires that all
relevant policies be in place. Unfortunately, policies are often
being developed at the same time as training materials. We have
seen many examples of this in the past months: lack of clear procedures
for handling and disposal of AD syringes in immunization programmes
where staff have always used sterilizable equipment; lack of clarity
about whether ADs would be used for all immunizations; confusion
about new policies for the use of multi-dose vials; and the need
to design record forms which can be reproduced in the training manual.
Sometimes, early on, there is confusion about which AD syringe and
which disposal box will be provided. This can also delay the creation
of instructions for use. Ideally, all procedures, policies, equipment,
and forms will be on hand when the training materials are designed,
but in our experience that is seldom the case there are always
loose ends. A good trainer will adapt the curriculum as conditions
|A good start: a nurse in
Cambodia immunizes one of the first children there to receive
hepatitis B vaccine supplied by GAVI and the Vaccine Fund, summer
Train staff first, then increase
demand for immunization
Most countries are rightly keen
to increase demand for their immunization services as a key step
towards strengthening the programme. But we feel strongly that staff
should first be trained, and new procedures should be running smoothly,
before demand on those services is significantly increased through
public education and advocacy. There are several reasons:
- First, consumers will ask about changes in the
programme and staff must have been trained to effectively deal
with those questions and concerns;
- Second, if consumers at the clinic get the feeling
that staff are not adequately prepared to use AD syringes or to
deliver new vaccines, confidence in the quality of care erodes
and will be difficult to rebuild;
- Third, once trained in interpersonal communication
and social mobilization, staff can become key agents for creating
Who pays for training?
Staff training is often funded by governments
or NGOs themselves, but sometimes supplementary funding is necessary.
Countries approved for assistance from the Vaccine Fund for infrastructure
strengthening might choose to allocate some of their resources to
training. In other situations, Alliance partners in a given country
may be willing to pay for some, or all, training costs. What matters
is that the immunization partnership in the country recognize the
need for the development of human resources as a high priority.
Given the political will, countries will find a way to mobilize
NGOs can be highly effective partners
Even though the bulk of immunizations
worldwide are provided by governmental agencies, NGOs vaccinate
many children each year and contribute other support to immunization
too, such as the work described here. Sometimes NGOs are members
of national Interagency Coordination Committees. And, since many
NGOs have already developed strong training programmes for their
own health workers, they may offer good models for the government
2: Examples of training initiatives
developed by the Gates Children's Vaccine Program at PATH,
in close collaboration with Ministries of Health, NGOs, and
other GAVI partners:
Andhra Pradesh, India (2000
- Rapid assessment of attitudes towards
immunization in service providers and consumers
- Development of curricula for managers and
- Training of trainers programme
- Assistance with training 4000+ staff
- Provision of resource documents for
- Recruitment of training expert to work with
Nepal (2000 and 2001)
- Audience research into attitudes towards
injections and injection practices in both the private sector
and the EPI programme
- Workshops on immunization strengthening,
adapted for regional needs, Africa (2001) and Eastern Europe
Some immunization topics require
Our audience research findings, and
experience since then, have stimulated us to pay special attention
to certain topics when designing immunization training programmes:
Hepatitis B issues
- Make sure that audiences get all the information
they need on the new vaccine3.
- Be sure vaccinators understand that hepatitis
B vaccine must not freeze, and how they can avoid freezing it.
- Communicate instructions specific to the vaccine
used in your country. Hepatitis B vaccine is available as a stand-alone
vaccine, in combination with DTP (quadrivalent vaccine), and in
combination with DTP and Hib (pentavalent vaccine). Each combination
has different advantages: the quadrivalent vaccine does not require
reconstitution and therefore requires less time and fewer steps
to administer; on the other hand, the pentavalent vaccine delivers
an additional antigen.
Train health workers to deal with
certain issues specific to measles immunization:
- Proper reconstitution of the vaccine and handling
and disposal of reconstituted vaccine.
- Challenges associated with the childs age.
Measles vaccine is given later than most childhood vaccines. Older
children squirm more during immunization. By this stage, the mother
has resumed her normal duties and may not have as much time to
bring the child to the clinic. And because older children eat
supplementary food, they are at increased risk of diarrhoeal disease.
Mothers are less likely to bring a sick child for immunization.
- Make sure policies are clear about how health
workers should deal with multi-dose vials. A number of health
workers told us that they are not willing to open a twenty-dose
vial for just a few children.
- Help staff to promote the value of measles immunization,
and to understand the dangers associated with the disease and
Injection safety issues
- Anticipate confusion related to "unusual"
packaging. When provided in bulk, AD syringes are sometimes packaged
without an individual plastic wrapper and without a packaging
expiry date printed on each unit (the manufacturing date is printed
on the box holding the bulk syringes). This is confusing to health
workers accustomed to individually packaged disposable syringes
they have been taught that unopened wrappers suggest that
the syringe inside is sterile. While the new AD syringes are sterile
(they are adequately protected by plastic sheaths over the needle
and the plunger), people in the field need to be reassured that
this is true.
- Dont underestimate the difficulty of some
"mundane" tasks. Experience over the last few months has demonstrated
that some of the disposal boxes delivered with AD syringes are
a bit tricky to assemble. Anyone can learn to do it, but it requires
a little coaching and practice.
- Clearly communicate realistic procedures for handling
and disposal of filled safety boxes.
- Finally, BCG immunizations are particularly difficult
to administer. Extra time should be allocated to practising intra-dermal
The prospect of training thousands of
health workers, their managers, and others can be daunting, but
improving staff skills and knowledge is one of the best investments
we can make. It is especially important to meet this need when we
have such a tantalizing goal: making sure that all children have
access to the vaccines they need. Training becomes more crucial
than ever in the era of GAVI.
Scott Wittet is Director for
Advocacy, Communication, and Training for the Bill and Melinda Gates
Childrens Vaccine Program at PATH
References and notes
and Wittet, "Perceptions about Injections and Private Sector Injection
Practices in Nepal" (2000) and "Rapid Assessment of Perceptions,
Knowledge, and Practices Related to Immunization Injection Safety
in Nepal" (2001) are both available on the web at www.childrensvaccine.org/html/safe_injection.htm.
2. A further note
about the need for support from managers: you may wish to organize
trainings for these staff prior to those for vaccinators. In that
way you can deal with questions and concerns ahead of time and get
a better response when calling for vaccinator trainees later on.
3. See Immunization
Focus March 2002, pp
6-7, for more on this topic.
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