Participants’ sociodemographic characteristics
This paper examines the data from qualitative interviews with 60 participants. Of the 60 participants, 53% were healthcare workers (nurses, clinicians and pharmacists); 22% were healthcare administrators (district medical officers, reproductive and child health coordinators and programme officers); 17% were community health workers; and 8% were mothers of young infants with PSBI.
Key themes and subthemes
The results were heuristically grouped into three themes, namely: feasibility of DIMCI, efficacy of DIMCI, and cost efficiency of DIMCI. To consider feasibility, we examined issues related to course structure and organization, course beneficiaries, course contents, course delivery, mentorship, supportive supervision and follow-up, and availability of job aids. We then compared DIMCI with the standard IMCI training. To consider efficacy, we examined participants’ descriptions of the success of DIMCI implementation. Finally, to consider cost efficiency, we examined issues related to the cost of implementing the DIMCI programme. These issues are examined in detail in subsequent sections.
Feasibility of DIMCI
Findings related to feasibility of DIMCI were sevenfold. The first issue related to feasibility of DIMCI from the implementation standpoint was course structure and organization. Project documents indicated that frontline health workers were trained through a 10-week distance learning course that consisted of three face-to-face meetings (facilitators and trainees) and two self-learning periods of 5 weeks each. The face-to-face meetings consisted of both classroom and clinical practice sessions in a nearby facility. During qualitative interviews, participants described the DIMCI course as including a brief face-to-face orientation session, several weeks of self-learning, group discussions within the facilities and/or neighbouring facilities, and brief face-to-face examination and review sessions. The complete training package was described as running for 10 weeks, with flexibility allowed in the schedule. The training schedule appears to have been pre-determined by the facilitators, while a consensus -building strategy was applied for the self-study and group discussion component after orientation. As a staff member from the Ministry of Health described:
(DIMCI) runs for 10 weeks. [Participants] study for 5 weeks, come for the review session, then do five more weeks and come again and do the exam, which results in being awarded a certificate. There are three phases. They have 1 day for orientation, then they are given modules for self-reading. The orientation day includes the meaning of DIMCI and the guidelines they will use; they are given DVDs, guidelines and other materials covering several days [of the training]. Before they leave, they are put into study groups because there are days for self-reading and for group discussions. The group discussions have a chairperson. They develop a learning schedule and decide on topics for individual learning and group discussions. There are also groups for watching DVDs because we know some people residing in rural areas do not have TVs and some have no laptops, or don’t know how to use laptops. That is why they plan among themselves. (Ministry of Health staff member)
The second issue related to feasibility of DIMCI was course content. The DIMCI training manual indicates the course contents as including: identification of signs such as fever, breathing rate, cough, diarrhoea, and ear problems; classification of severity of newborn based on their signs; management of identified newborn illness; education of mothers on home-based care and treatment; close follow-up of sick infants and documentation and reporting. During qualitative interviews, the contents of the DIMCI training were described as focusing on management of diseases of young children, including identification of danger signs, assessment and classification of severity using chartbooks, treatment and reporting. Specific newborn diseases covered included bacterial infections, diarrhoea and malaria. Decision-making was also covered, including referral decisions and initial management before referrals (e.g., dosage), as well as use of reporting tools and electronic system. Some participants commented:
The IMCI training focused on diseases affecting young children, how to detect and investigate them, how to classify them as very severe, severe or not severe, and also treatment. We were also trained on how to use chart books for classification and filling the reports. (Trained HCW, Mbarali).
There were topics on classification of young children, topics on diarrhoea, malaria and other diseases affecting newborns, but also classifications of severity. There were also topics on management after classification, deciding on the need for referral, the services that must be offered before referral, and what to do if someone refuses referrals. They were therefore trained on complete management, dosage and duration, filling the tools and using electronic system in general. (Health administrator, Kyela).
The third issue related to feasibility of DIMCI was the course beneficiaries. The project committed to training nurses and clinicians, specifically those working at the dispensaries and outpatient department of health centres and district hospitals through DIMCI, as they are directly- involved in newborn care in these facilities. Project documents indicated that a total of 430 health workers (covering 80% of eligible primary health care health workers) were trained from 174 health facilities (100% of health facilities in the project districts at the time of training). Qualitative interviews indicate that nurses and clinicians (clinical officers, assistant medical officers and medical doctors) were the main beneficiaries of the DIMCI training. The participant selection was described to be conducted by the district IMCI focal person following criteria set by the Ministry of Health. The selection criteria were based on cadres, primary responsibilities, level and ownership of facilities and areas with high numbers of young children. At least two participants were selected from dispensaries, including in-charges, nurses and in some, medical attendants. During qualitative interviews, the percentage of facilities in which HCWs participated in the training emerged as high, with some participants citing coverage ranging from 80% in Busokelo (reported by a trained HCW), 90% in Kyela (reported by a trained HCW) to 98% in Mbarali (reported by a health administrator). In Mbarali for example, 119 HCWs were cited as trained on DIMCI, although the target was 300. It is important to note that the reasons for not reaching the target were not clearly unpacked in qualitative interviews:
We looked at cadres considering nurses and doctors according to the guideline, but most came from dispensaries because they are highly engaged in referrals. In all, we had 119 participants, although the target for the training was 300, because some faced different challenges that limited their participation. Therefore, we had facility in-charge nurses and other nurses, but there are some facilities in which medical attendants participated. We also had at least 1-2 participants from private facilities that offer outpatient care. We concentrated more on areas where we could get many young children. (Health administrator, Kyela).
Since the project primarily deals with reproductive issues, most of the participants selected are those who are engaged in reproductive issues, including nurses. Each facility produces about two participants working in reproductive health. We have 58 facilities, but two facilities are new. Therefore, about 98% of all facilities participated except new facilities, which had not been established when we developed the plans. (Health administrator, Mbarali).
The fourth issue related to feasibility of DIMCI was course delivery. During qualitative interviews, as noted above, the delivery of DIMCI was described to include a mix of brief face-to-face orientation and review sessions, self-learning and group discussions. During brief face-to-face orientation and review sessions, DIMCI content was presented via presentations and demonstrations by facilitators, group discussions and assignments, and homework. Participants who described self-learning mentioned being given course modules, IMCI chart booklets, educative CDs/DVDs, IMCI photographic books, logbooks containing IMCI recording forms, and exam sheets. They further described meeting for group discussions, using the WhatsApp messaging platform for learning, as well as phone calls with facilitators for support when needed. Phone communication with facilitators was a concern because participants were responsible for the costs involved. This may have somewhat limited the frequency of calls, although such affirmations did not specifically emerge in the data. One participant commented:
[Facilitators]were sending us photos of sick children recorded on CDs and we were also using books for reading and guiding treatments. To ensure that we were studying, they gave us exams that were collected and marked every time we met. Also, they gave us phone numbers for consultations whenever we faced any challenge, but we had to cover the cost of calling. There were study groups; each group had a leader and we used to agree on a meeting place for discussion on the cases using books and CDs. We used to communicate through SMS on where and when to meet, and the agenda and discussion questions. We used a computer to watch CDs (HCW, Mbarali).
The fifth issue related to feasibility of DIMCI was mentorship, supportive supervision, and follow-up. Recognizing the importance of ongoing support after the training, the Ministry of Health and partners developed the ‘Guideline for follow-up after IMCI training’. This document provides guidance on key issues that need to be considered during follow-up after any IMCI training, with the purpose of reinforcing the new skills gained by participants and solving problems encountered in the course of implementing IMCI. A focus of mentorship and follow-up is, therefore, case management skills, health facility support (including availability of essential drugs and commodities for child health), and documentation and reporting of services offered. When asked about mentorship, supportive supervision, and follow-ups during the DIMCI programme, mixed descriptions emerged. Some participants described phone-based mentorship and follow-up by facilitators through WhatsApp and direct phone calls. Others mentioned brief face-to-face assessment and review assessment sessions after the participants had undertaken the assigned self-directed modules. In addition to assessments, the brief face-to-face review sessions with facilitators were cited as including discussion on challenges encountered during self-directed learning and clinical practice and distribution of additional modules. One participant commented:
[Facilitators] came for follow-up after a certain time where they came to administer exams based on the modules we were given. For example, if we were given five modules, we were required to read them and answer the questions. When they came, they would ask for the assignments for marking and feedback. They asked about the challenges encountered on the modules and we discussed them together. Then they gave more modules for reading and responding to the questions, as well as the date for the next face-to-face session. (Health administrator, Busokelo).
The sixth issue related to feasibility of DIMCI was availability of job aids. When asked about job aids, most participants cited learning materials such as modules, recording forms and DVDs. Likewise, child assessment and treatment decision-making materials, including IMCI chart books were noted. Additionally, reporting books or registers were reported to be offered by the project. While some participants described pre-existing working tools such as computers in their facilities, others cited logbooks and guidelines as the job aids provided. It is not clear whether participants were able to make full use of these materials; however, assessment of the logbooks during face-to-face review sessions was cited as an important monitoring strategy (see above).Regarding job aids, one participant commented:
After finishing the training, I was given 13 books, including guidelines and logbooks. Each book described a certain disease, such as diarrhoea and others. We were required to read, answer questions, and fill out the logbooks for the module that we had completed. (Trained HCW, Mbarali).
They are given mother’s cards, charts books, 14 guidelines and DVDs. (Ministry of Health staff member).
The problem with job aids, in particular the materials for self-learning DVDs, was inadequate facilities for viewing them, such as TVs and computers, concerns about the durability of DVDs (and consequently recommending that DVDs be converted into flash discs), and language barriers, with some recommending translation into Swahili for consumption even with low staff cadres. However, concerns about the cost of converting contents into flash disc were likewise highlighted as a potential limitation to this recommendation. Some participants commented:
Some of us failed to answer the questions because they did not have facilities to watch the DVDs, and some encountered problems in using DVDs. (Trained HCW, Mbarali).
There were some challenges with DVDs. People living in rural areas take Bodaboda [motorcycle taxis] after class, which makes it easy for DVDs to scratch and they cannot be read afterwards [laughs]. Some do not have TVs or electricity, meaning they may need to watch from a neighbour’s home, after incurring the cost of fuel for generators. What they need to do is first convert them to flash discs and second translate DVDs into Swahili because they are in English, [a language] that people like medical attendants are not conversant in. (Ministry of Health staff member).
The seventh and final issue related to feasibility was the comparison of DIMCI and the standard IMCI training. Qualitative interviews went further to explore participants’ perceptions about the differences between standard IMCI and DIMCI, with mixed views emerging. To better understand the comparison, we used heuristic criteria in describing the difference between DIMCI and standard face-to-face IMCI trainings. The first comparison criterion is the cost perspective. Participants were asked about their perceptions on the cost difference between the two models of IMCI training. Looking across transcripts, disagreements emerged regarding the cost of DIMCI compared with traditional face-to-face training. Most participants appeared to be unaware of the specific cost of DIMCI, but were able to offer comparisons. The majority of participants believed that the cost of DIMCI was less than the cost of traditional face-to-face IMCI trainings, as face-to-face trainings would require costly materials, such as venues, per diems, transport and prolonged engagement (i.e., number of days). DIMCI was therefore considered a cost-saving training approach by many participants, with one describing a cost reduction of 70 to 75%. Although both types of training require facilitation and training materials, the fewer number of days required for face-to-face orientation and the ability to train many participants at once were considered as the main cost-saving drivers of DIMCI:
If we talk of resources, we consider cost reduction, which is 70% in distance learning, but other processes, including having a teacher come to teach, are almost the same. (Programme manager, Mbeya).
The cost per [DIMCI] participant is around US$340–400, but previously, [with IMCI] it used to be $1000. Therefore, the cost reduction is around 75% for DIMCI, including training materials plus follow-ups, but the (IMCI) used to be $1000 without follow-ups. (Manager, Mbeya).
Resources used for distance learning cost less than those for face-to-face training because when you invite people into a classroom you have to prepare notebooks, pens, pay for venue, food and transport. (Trained HCW, Busokelo).
On the contrary, another group, comprised of a few participants, suggested that DIMCI may be expensive compared with face-to-face sessions. The need for face-to-face orientation and review sessions, materials for self-reading and the time-consuming nature of DIMCI were considered as the main drivers of cost compared with the standard IMCI. This suggests that for the cost of DIMCI to be less than that of standard IMCI, the training would need to be completely self-led, without any form of face-to-face interaction:
I think distance learning may be expensive compared with face-to-face training because the latter runs and ends within a specific period. But distance learning involves meetings and being given assignments that you go and do. Then you come together to look at what you learned individually and you are given the next assignments. Therefore, it takes longer than face-to face learning. (Trained HCW, Mbarali).
The second comparison criterion is beliefs on retaining the knowledge gained. Maximizing knowledge retention is a critical aspect of any training; if effective, it can reduce the need for frequent refresher trainings. Except for a few participants who considered the two approaches equally effective (i.e., having the same quality and knowledge decay potential), many considered standard face-to-face IMCI as having a higher likelihood of retention of the knowledge gained compared with DIMCI. The perceived drivers of high knowledge retention were an opportunity to gain more knowledge by prolonged interaction with facilitators conferred by standard IMCI compared with DIMCI. This was evident in the accounts of some trained HCWs who had first-hand experience with DIMCI:
Learning through face-to-face has the potential to sustain knowledge for a long time. After all, a person studying face-to-face gains richer content and has more time to learn more things from facilitators, compared with distance learning. During face-to-face you interact and exchange ideas on many issues with facilitators, and you discuss with your fellows as well. The knowledge sticks in your mind for a very long time and you can use that knowledge to work effectively (Trained HCW, Busokelo).
On the contrary, some macro-level participants suggested that DIMCI had more potential for knowledge retention than standard face-to-face IMCI. These assertions were very common in the accounts of WHO staff, who drew these conclusions from their rationale for developing the DIMCI programme or from their experiences in implementing the previous pilot project:
After some time, skill retention was much better with DIMCI than with the standard IMCI because those in the standard scheme just went back after completing the course...but those in DIMCI had more time for self-reading and practice because they were more committed. (WHO staff member).
The third comparison criterion is the work-study balance advantage. Since the trained HCWs are employed and working at healthcare facilities, a training that allows participants to study while continuing their regular work offers more work-study balance. Some participants affirmed that DIMCI provided more work-study flexibility compared with the standard face-to-face IMCI learning. Work-study flexibility was considered critical in maintaining the healthcare workforce at the facility, as it allows HCWs to fulfil their routine duties while studying. The standard IMCI was considered to offer less work-study balance because of the need for participants to attend trainings away from the workstation for a long time, creating a workforce deficit that negatively impaired service provision:
Personally, I think DIMCI is good because a provider continues with normal work while studying. Assignments and scenarios will be sent, the provider reads the reference books, responds, and continues working. Many facilities will remain empty if the contents are delivered face-to-face and providers must attend (face-to-face) trainings, because the topics are very long, and they study for a very long time. Therefore, it will contribute to a staffing deficit at the facility and impair services. DIMCI is good because they study and continue offering services. (Health administrator, Busokelo).
[DIMCI came because] people were complaining about the problem with face-to face training – that it requires taking a provider away from a workstation for almost 2 weeks, meaning people were missing the services. That is why it was necessary to come up with a modality in which the provider is taken away for a very short time, but receives the same content as if she or he were taken for a long time. (National trainer of trainers).
The fourth comparison criterion is the potential to allow reflective critical thinking. Aside from one participant, who considered both DIMCI and face-to-face trainings as having the same quality, some felt that DIMCI provided more opportunities for reflective critical thinking on the content than standard face-to-face IMCI training. Self-learning in DIMCI was said to allow for self-reflection among participants, while the standard face-to-face IMCI was considered to be a form of ‘spoon feeding’ the contents. Some went further to suggest that DIMCI increased the motivation for self-directed study compared with standard face-to-face IMCI:
Distance learning facilitates learners’ capacity to think more critically and expand their thinking on their own, compared with trainings where you are taught everything. Because in distance learning, imagine you meet a case, you must discuss among yourselves as providers, challenge and correct one another until you reach current management. [This is] unlike ‘spoon feeding’ in a classroom, [where] everything is taught by a trainer. (Health Administrator, Kyela).
IMCI did not build the culture of self-study and people had lost motivation to study, but DIMCI built a studying culture. You may find a facility has three to four staff and they can study together and motivate each other. DIMCI has facilitated easy implementation because learning occurs at the facility; therefore, a HCWs implements everything she or he studies at the same facility. (WHO, staff member).
The fifth and final comparison criteria is the number of beneficiaries. There was broad consensus among participants that DIMCI offered an opportunity for more people to learn at the same time, compared to the standard face-to-face IMCI training. This indicates that DIMCI has the potential to reach more people than the standard IMCI, especially if no face-to-face orientation sessions are included. Furthermore, DIMCI was considered to offer more opportunity for skills practice because participants had greater access to sick newborns at their workstation during self-directed learning, compared with limited interaction with cases during standard face-to-face trainings:
Distance learning is very good because many people get educated at the same time, instead of taking one person from the facility to go attend the training for seven or 14 days. (HCW, Mbarali).
During standard IMCI, it was difficult to get sick newborns for practice; therefore, we ended with just demonstrations. But with DIMCI, they can access sick newborns at the facility every day and they were able to go to a nearby facility or visit them at home and they had more time to do assessments of young children. (WHO staff member).
Efficacy of DIMCI implementation
Participants cited several successes arising from the application of the skills they had gained through the DIMCI training programme, including: (i) improved knowledge among HCWs on IMCI; (ii) improved management of under-five children due to improved knowledge and skills; (iii) improved quality of care and; (iii) improved happiness among providers and service users. According to participants, increased happiness among service users was largely influenced by reduced waiting time and improved friendliness of healthcare providers (detailed previously). Such improvements were highly linked to the DIMCI training; they not only contributed to reducing newborn and maternal deaths, but will likely continue reducing deaths of newborns and mothers in the future:
Providers became very happy. Service users became very happy. Services were accessible. Community health workers were available and working responsibly. We have reduced deaths to a large extent. (UNICEF staff, Mbeya).
This project is very good. The project has brought many successes, especially in offering care to under-five children. Most providers did not have a good understanding of the management of young children, but this has improved after the distance learning, especially after learning through modules and practising afterwards. They use chart books; they have the capacity to refer and know what is needed. I believe in the next 10 years, deaths among under-fives will be reduced significantly, because even now, you can’t compare with what was happening before. (Health administrator, Mbarali).
Another success cited by participants was improved confidence and capacity to identify and manage problems experienced by young children through a classification process using chartbooks. This was the dominant success cited in relation to the knowledge and skills gained through the DIMCI training. Increased confidence in managing newborn diseases among healthcare workers was likewise linked to reduced newborn referral tendencies from low to higher level facilities compared with the pre-project period. Furthermore, there was an affirmation of improved use of the IMCI guideline for management of childhood diseases. Increased use of the IMCI guideline among healthcare workers for treatment decisions may have contributed to improved management of newborn diseases:
One of the important benefits is increased confidence of healthcare workers in managing newborns. Before that, HCWs at lower levels were just referring newborns, even if they had the capacity to manage. Therefore, DIMCI built the capacity of HCWs to manage young children at low levels. (WHO staff member).
Personally, the successes I have witnessed include children who met the criteria for severe diseases after using classification procedures. This has simplified our work because we do not need to use complex investigations to detect problems that a child is suffering from. You just open your chart book and classify the baby based on the symptoms described by the mother. This has made it easy to discover the problems troubling the child and offer effective treatment as part of IMCI. (Trained HCW, Mbarali).
The training was good. Initially, I did not know how to recognize a child with pneumonia but now I can detect him/her. I can treat the baby (with pneumonia) very well without any problem. In short, the training has helped us a lot; for example, if the doctor is not available, I can sit and treat a baby without any problem. (HCW, Mbarali).
The cost efficiency of the DIMCI programme
Qualitative interviews went further to examine training costs. Looking across transcripts, there was broad consensus among participants that they were unaware of the cost of DIMCI trainings. Most participants, such as trained HCWs and district administrators, such as district medical officers and district RCH cordinators used phrases such as, ‘I cannot talk about it’ or ‘I don’t know the cost incurred’. Such statements suggest that the DIMCI budget may not have been shared with district authorities and participants. However, few health administrators went ahead to mention cost items, such as per diems paid during a brief face-to-face DIMCI orientation training (TZS 80,000 for each participant from the district). Other costs included transport refunds, food, venue and stationery, particularly during the brief face-to-face sessions within DIMCI training. One health administrator approximated the cost of DIMCI to reach about TZS 27 million per session:
I cannot talk about the cost of training because I do not know how much the [PSBI] implementers used, but on our side, we paid a large cost, especially during participant meetings with facilitators. (Health administrator, Kyela).
The cost per participant for the per diem at the district was TZS 80,000. Transport was also refunded at about TZS 10,000 each. I did not capture the full cost because the activity was coordinated by Catholic Relief Services and UNICEF. But there were also food costs; I don’t know how much they paid. There was also stationery, including notebook and printed papers. Also, they hired three venues, so almost TZS 14 million and TZS 40,000 may have been used per participant. We had seven facilitators; I don’t know how much they were paid, but let us say they got TZS 150,000 … they may have used TZS 9 million each, making a total of around 27 million (Health administrator, Mbarali).
