Validation of Training Need Assessment Questionnaire Among Health Care Workers in Reproductive, Maternal and Newborn Health Care in Low-Income Countries


 Background: Continuous professional development (CPD) trainings have been reported to enhance health care workers’ knowledge and skills, improve retention and recruitment, improve quality of patient care and reduce patients’ mortality. This calls for validated training needs assessment tools for facilitating the design of effective CPD programs. Methods: A cross-sectional survey was conducted using self-administered questionnaires. The survey involved selected Reproductive, Maternal and Neonatal Health (RMNH) health care workers from 7 hospitals, 12 of 51 health centers and 17 of 292 dispensaries within eight districts of Mwanza Region, Tanzania. The training needs assessment (TNA) tool adapted from the Hennessy-Hicks’ Training Needs Assessment Questionnaire (TNAQ) was used for data collection. Results: A total of 153 healthcare workers participated in this study. The majority of participants were females 83% (127) with average age of 39 years. Nurses formed a majority of participants 76% (n=115) with relatively similar mean duration in service or in RMNH of 7.9 years. The reliability of the adapted TNAQ was found to be 0.954. Relatedly, indexes for construct validity indicated that CFI was equal to 1, Chi-square Mean/Degree of Freedom (CMIN/DF) was equal to 0.000 and Mean Square Error Approximation (RMSEA) was equal to 0.185. Conclusion: The adapted TNAQ appear to be reliable and valid for identifying professional training needs of health care workers in RMNH health care settings. The tool has a considerable level of psychometric properties that makes it suitable for assessing the training needs among health care workers of different cadres. However, the applicability of the TNAQ in the wider health care systems remains unclear. Future studies with a large sample size are required to test the use of TNAQ in wider health care systems and learning opportunities.

addition, the national Neonatal Mortality Rate (NMR) remains high, at 25 deaths per 1,000 live births (2). While there are many drivers of poor maternal and newborn health, a shortage of skilled human resources for health plays a major role in low income countries, particularly in the rural areas.
Continuous professional development (CPD) trainings have been reported to enhance health care workers' knowledge and skills, improve retention and recruitment, improve quality of patient care and reduce patients' mortality (3,4). Skilled healthcare staff plays a vital role in ensuring optimal RMNH practices by communicating with care and respect, and having the requisite knowledge and technical proficiency (5). In other contexts, an estimated 20-21% of neonatal deaths can be prevented by healthcare workers' promotion of simple, evidence-based practices such as exclusive breastfeeding and hand washing, and the prevention of hypothermia and infection (5,6) Unfortunately, skilled staff are often not available or adequately supported as patient disrespect, patient abuse, low provider confidence and low provider skills remain commonplace in many settings (7).
One of the important tools in identification of the health care workers' knowledge and skills gaps and establishment of future CPD training profile is the training needs assessment (TNA) (3). A context specific TNA can facilitate accurate assessment of healthcare workers training needs for the successful implementation of RMNH programs (8). Furthermore, a validated TNA tool for assessment of training needs in low income countries might be helpful in identifying the underdeveloped skills, insufficient knowledge or inappropriate health care workers' attitudes. Despite the contribution of the CPD trainings in reducing MMR and Neonatal Mortality Rate (NMR), research shows that TNAs in many organizational settings have been done in an unsystematic manner or used tools that are not validated (9). This calls for validated TNA tools for facilitating the design of effective CPD trainings.
The Aga Khan Development Network (AKDN) is working with the Ministry of Health, Community Development, Gender, Elderly and Children in Tanzania (MoHCDEC) towards Improving Access to Reproductive, Maternal and Newborn Health in Mwanza, Tanzania (IMPACT). The IMPACT project combines training with mentorship interventions that has been reported to be an important strategy for in-service healthcare workers support for skills and capacity transfer (10), as a result, improve RMNCH outcomes (11). Through the project's baseline survey, we conducted TNA of reproductive, maternal and newborn healthcare workers in Mwanza Region. The IMPACT Project team developed the TNA tool with adaptation of the construct of items from the TNA questionnaire developed by Hicks in 1996 (12). The Hennessy-Hicks TNAQ was developed for evaluating training needs and priorities of the health care professionals and it has been used in both developing and developed countries (12)(13)(14). Thus, this study validated the TNAQ in the local Tanzanian context with the goal of facilitating development of effective need-based CPD trainings for improving health care workers' competence in the delivery of RMNCAH services in Mwanza region.

Material And Methods Study Area
Mwanza region is bordering Lake Victoria located in the northern part of Tanzania The region is part of the Lake Zone where the maternal mortality rate was 453 deaths per 100,000 live births and under-five mortality rate was 88 deaths per 1,000 live births in the 10-year period preceding the TDHS 2015/16 and, these rates failed to meet Tanzania's MDG targets (2). The neonatal mortality rate of Mwanza region in 2015 was 29/1,000 live births which remains higher than the national average of 25/1,000 (2). National data indicates that among pregnant women, only 50.7% attend at least 4 recommended health facility visits for focused ante-natal care (FANC) during the last pregnancy (2). Health facility deliveries in Mwanza region account for 63.6% on average, while large disparities within the region persist with 87% deliveries occurring in facilities in urban areas versus 54.7% in rural areas (2). With the focus on its poor RMNH indicators, Mwanza region is one of five prioritized regions in Tanzania targeted by the Government (2). Understanding the training needs of healthcare workers in Mwanza region forms an important entry point for the IMPACT project in seeking to increase their contribution towards improving RMNH indicators. This created a need for validating the TNAQ in Mwanza Design A cross-sectional survey using self-administered questionnaires was conducted. The survey involved RMNH healthcare workers at selected health facilities in all eight districts of Mwanza Region, Tanzania. Thus, all district hospitals were included owing to their number, and 63% of health centers and 32% of dispensaries within IMPACT Project were considered sufficient to provide the required study power for the purposes of monitoring and evaluation. The relative homogeneity of dispensaries in terms of infrastructure, service provision, and human resources was also a reason for selecting one-third of the IMPACT Project's target dispensaries.

Study Population
All adult health workers responsible for RMNH service provision and present in the facility at the time of the survey were eligible to participate. The specific inclusion and exclusion criteria were as follows:
Health care workers who were found in RMNH but not usually working in such a unit.

2.
Healthcare workers unable to answer questions because of physical or/and mental impediments 3.
Healthcare workers not willing to participate.

Data collection
Data collection took place in August 2017. The administered TNA questionnaire was designed for providers of RMNH at the primary (dispensary and health center) and secondary (health center and district and designated district hospital) levels. As noted above, the tool was adapted from the Hennessy-Hicks TNAQ instrument (12,15), which has been psychometrically tested for reliability and validity and adopted by the WHO (15). The Hennessy-Hicks instrument has been similarly adapted to assess the training needs of different health care practitioners in a range of cultural contexts (12,15,16). In the adaptation of the TNAQ, the pooled items were obtained from literature review and expert opinion basing on their experience in the field of reproductive health. These pooled items were validated by the health expert panel with expertise in teaching, reproductive health, research and local culture including customs, traditions and local languages (Kiswahili). The adapted TNA tool divides questions into broad categories, allowing for both intra-category and inter-category comparison of training needs.
During data collection, the person in-charge of the selected facility identified the RMNH personnel to whom the questionnaire was given for completion. Participants were requested to assess their own performance and rate the importance of specific RMNH services/activities through a selfadministered, confidential paper-based questionnaire. The questionnaire asked participants how each RNMH related activity is important to the successful performance of their work and how well they considered their performance in each activity with each item in the questionnaire rated along a seven-point Likert scale. Participants were also asked to identify areas in which they most wanted to receive additional training and the trainings that they had most recently completed. Research assistants were on hand to answer questions and clarify elements of the questionnaire. The returned forms were checked for completeness and accuracy before leaving each health facility.

Data management, analysis and interpretation
The Statistical Product and Service Solutions (SPSS, version 20.0) was used for data entry and statistical analysis. Data from the questionnaires were reviewed to identify consistencies and differences, coded and quantified. The data were then manually entered into a password-protected database via an entry screen that performed validation checks for accuracy. The missing data was excluded during analysis.
The TNAQ was validated through a three-phase process: The Exploratory factory analysis which is a statistical method that helps to identify a set of latent constructs underlying a battery of measured variables (18). In order to make the interpretation of factor analysis, the first step is to extract a set of factors (relevant factors) from a data set, then rotation of the remaining factors (19,20). Rotation makes the output more comprehensible through formulation of the structure so-called "Simple Structure" (20). Two main types of rotations are used; orthogonal; when the new axis are in orthogonal to each other and oblique; when the new rotations are free to take any space. The promax rotation is an alternative non-orthogonal (oblique) rotation method and it is computationally faster than the direct oblimin method. Therefore it is sometimes used for very large datasets.
The reliability of the TNAQ was assessed. Internal consistency was measured by Cronbach's alpha coefficient with 0.7 indicating acceptance of the instrument. Construct validity was evaluated by EFA and CFA. The EFA was conducted using Principal axis factoring estimation with promax rotation that facilitates the determination of the underlying factor structure of the items and it has advantage of being fast and conceptually simple (21). The factor retention applied the following criteria: (a) eigenvalues greater than 1.0, (b) the percentage of total variance explained, (c) scree plot, and (d) factor loadings above 0.40 were retained. The CFA was determined by using generalized least squares estimation to compare the current and the original 5-factor model of the scale. The model fit was considered acceptable if χ2/df < 2, adjusted goodness-of-fit index (AGFI) > 0.9, comparative fit index > 0.9, goodness-of-fit index (GFI) > 0.9, root mean square error of approximation (RMSEA) < 0.04, and incremental fit index (IFI) > 0.9 (18,22).

Results
A total of 153 healthcare workers participated in this study. The majority of participants were females 8.73% (128) with average age of 39 years. Nurses formed a majority of participants 76% (n = 115) with relatively similar mean age in service or in RMNH of 7.9 years. The details for sociodemographic data are provided in Table 1.

Clinical experience
The majority of participants indicated having experience ranging between 0 to 5 years in both general health care services and RMNH. Table 2 offers more details.

Construct Validity Testing
As shown in Table 4 below, the TNAQ retained all the 49 items and displayed three-factor structure.
Factor 2 included item number 13 Comprehensive emergency obstetric and newborn care (CEmONC) activities that was named as CEmONC. Factor 3 included item number 29 (surgical care) and 30 (anesthetic care) and it was named as intra-operative care. All other remaining items formed factor number 1 that was named as general RMNH activities. The sign (positive or negative) indicates the direction that a given variable in the principal component is on a single dimension vector. The smallest value regardless of the sign (+ or -) indicates a small impact. Confirmatory Factor Analysis (CFA) for TNAQ The CFA was performed using generalized least squares estimation to compare the current and the original 3-factor model of the scale. A model was found to be good (X 2 /df < 3) and Comparative fit index (CFI) was found to at the best level (CFI = 1). However, the RMSEA was 0.185 indicating that it was bad as a smaller values indicate better model fit. Overall, the unsuitable index was ignored because other two indices were suitable, are commonly used and are more predictive. The summary of indices and its related threshold for interpretation are summarized in Table 5. Table 5 The measure for confirmability factor analysis indicated the model suitability for the Training need assessment questionnaire.

Discussion
The aim of this study was to validate the TNAQ in RMNH services within Mwanza Region, Tanzania.
The TNAQ was adapted from Hennessy-Hicks instrument (12), which has been psychometrically tested for reliability and validity and adopted by the WHO (12,15). The Hennessy-Hicks instrument has been similarly adapted to assess the training needs of different health care practitioners in a range of cultural contexts for instance it has been used in Indonesia (13) and in the UK (14)(15)(16).
Recently, in low income countries there is a higher demand for continuous development programs (23) that are not necessarily focusing on the actual professional knowledge and skills needs in the local health care settings (24). Therefore, TNAQ tool that is scientifically validated has a potential to provide a baseline for identification of training needs for RMNH primary health care workers in low income countries.
In this study, the reliability of the adapted TNAQ was tested and found to be 0.954. Relatedly, indexes for construct validity indicated that CFI was equal to 1 (CMIN/DF) was 0.000 and RMSEA of 0.185 was reported. These indices are within the acceptable threshold indicating excellent reliability and validity of the instrument. This suggests that the TNAQ is excellent tool for assessing the training needs on RMNH in Tanzanian context. The majority of Tanzanians are likely to share the culture such Kiswahili language is spoken by about 95% of Tanzanians. Moreover, expression of culture and training needs may reflect other low-income countries as the need and cultural background (10). A number of studies from different context and cultural background have reported similar psychometric properties (16,25,26). Therefore, the findings of this study suggest that the modified TNAQ that took into account the Tanzanian national guidelines on RMNH care, participants' culture including Kiswahili have acceptable reliability, design and content validity.
The exploratory factor analysis of training needs revealed the shared variance of three factors. This study finding is similar with another on translation and validation of Hennessy-Hicks -tool in Greek (27) that found the overall internal consistence of 0.98 (16). Furthermore, although reliability is important for the study, for a test to be reliable, it also needs to be valid (19,20). The internal consistence coefficient of 0.7 is agreeable by many scholars as a minimum (28,29). For exploratory or pilot study, the reliability coefficient 0.60 or above is acceptable (17).   (32). In this study the construct validity was at acceptable level.
Training need assessment is an initial step of a cyclical process contributing to an overall strategy of training and education (33).Training interventions are developed to meet the identified needs.
Meeting the training needs is certainly in the current Government Policy in Tanzania (34). Thus, the validated instrument with good psychometric properties will be helpful in analyzing the training needs and priorities of the health care workers.
The limitation of this study is fourfold. First, the study was a cross-sectional that provides only a snap shot in-time. However, the reliability and validity of competence include behavior and attitudes in health care industry can better be measured by a continuum-over-time basis (35,36 obtained from the Mwanza Regional Administrative Secretary. All participants provided oral and written informed consent after explanation of the benefit, potential harm, duration of the interview and the right to refuse or withdrawal from the study at any point when they feel to do so.

Consent for publication
Not applicable

Availability of data and materials
The data that support the findings of this study are available from Aga Khan University Monitoring and Evaluation Research Unit (MERL). There are some restrictions to the availability of these data due to license, so the data are not publicly available. However, the data may be made available from the authors upon reasonable request and with permission of the Aga Khan University Monitoring and   Scree plot with Eigenvalues to indicate the distribution of Principal components