Developing and Implementing Training Materials for Integrated Community Case Management in South Sudan

This learning paper discusses the adaptation of best practices for delivering training of Community Drug Distributors (CDDs) in the implementation of integrated community case management (ICCM) to the context in South Sudan. In two states of South Sudan, NBeG and Unity, between June 2010 and June 2012, the Malaria Consortium developed materials and implementation of ICCM training, including evaluating the effectiveness of training and revising it to ensure that CDDs learned standards of care that had positive impact on the health of communities. This paper looks at the process, challenges, and lessons learned from implementing ICCM training in this setting.

The paper explains that initial training materials developed were based on the World Health Organization/United Nations Children's Fund (UNICEF) standards and the ICCM training in Uganda. The materials included: an ICCM Training Manual, Training of Trainers Guide, Tick Child Job Aid, CDD Flipbook, CDD Recording Form, referral triangles used to track referral of sick children to the Primary Health Care Centres (PHCC)/Primary Health Care Centres Units (PHCU), and treatment cards containing child treatment instructions for caregivers. "CDDs are also given and taught how to use a respiratory timer to count the number of breaths in a child with possible pneumonia, a mid-upper arm circumference (MUAC) tape to measure the arm of a child with possible acute malnutrition, and medications to treat malaria, pneumonia, and diarrhoea....A training cascade system was used to deliver the training. This involved Malaria Consortium technical and adult learning experts training South Sudanese county health facility officers to become master trainers."

The mid-term review took place over three weeks during September and October 2011. Findings were as follows:

• The training cascade system hindered the delivery and transfer of consistent information by the time it reached the CDDs, resulting in incomplete content or diluted messages delivered to the CDDs. Also, the movement of experienced trainers to other work hindered refresher course implementation and cascade training of new staff.
• "Through skill observations and interviews it was found that the CDDs did not respond well to the method of teaching diseases individually and struggled to convert a disease by disease system into a holistic approach."

As part of the post review process, Malaria Consortium's case management and health training specialist was asked to revise all the ICCM training materials for Northern Bahr el Ghazal state (NBeG) in collaboration with the technical team in South Sudan. Malaria Consortium's response to the mid-term review recommendations was as follows:

• To overcome the problem of messages becoming diluted down through the cascaded training, Malaria Consortium hired and trained experienced health facility workers - nurses, health workers, or clinical officers - to become Malaria Consortium field trainers.
• In response to field trainer feedback on the English in the ICCM Training Manual, the technical content and facilitator instructions underwent a readability assessment and was revised to a 5th-grade level for translation to local languages.
• "In response to the low literacy and numeracy levels among CDDs, a series of 48 colour laminated instructional pictures were developed and used by the trainers as memorable and interactive visual aids. The instructional pictures were used to explain and test CDDs comprehension of the integrated process used in ICCM as well to ensure that CDDs could correctly match the patient's symptoms to the diagnosis and treatment for their age and illness. Instructional pictures also corresponded with the pictures in the Sick Child Job Aid and the CDD Recording Form. The issue of CDDs' limited ability to count above 10, and therefore unable to count the number of breaths, was addressed by dedicating a much longer period of time to training and practicing how to use respiratory beads along with a 60 second respiratory timer."
• A colour-coded CDD Competency Checklist and a system for certifying CDDs competencies at the end of training were developed. "The CDD Competency Checklist is used by the ICCM trainers during the clinical session on the fifth day of training to observe CDDs' skills and determine if they are competent to deliver ICCM in their community. CDDs need to demonstrate a satisfactory or 'OK' level in all skill areas in order to get a Certificate of Competence at the end of the training and receive their ICCM drugs."

After the NBeG team rolled out the new ICCM training package in June 2012, the Malaria Consortium brought together stakeholders including implementing non-governmental organisations (NGOs), Ministry of Health (MoH) staff, and donors to present the revision process, proposing that these materials form a foundation for review to move towards the production of harmonised materials.

Lessons learnt in the programme included the following:

• "It is crucial to conduct continuous evaluation of training and materials through extensive piloting, field testing, revision, and re-testing....
• Adult learning strategies start from what people already know.... Particularly key for the review was a focus on effective learning styles for low-literacy settings.
• The trainers found that the less translation required within a training, the better the flow of delivery and learning. As a best practice from the first phase, trainers worked in teams to ensure that all language groups spoken by the CDDs were covered. Where there was a mixed language group, the trainers often used a combination of Arabic or support from the CDD supervisor who had already been trained in the content. The revised training manual was written in simple English with short sentences. The technical content was simplified and included in the trainer instructions. As a result, trainers were able to easily translate it into Dinka or Luo at the same time as delivering the training.
• Pictorial training worked very well. Using this model adds an element of equality to the group as it is less significant whether members are literate or not or which language they speak. Pictorials also help trainers who do not completely speak the language of the CDDs to communicate key concepts.
• A glossary of terms/dictionary was included in the original training materials, and its importance was reiterated as a best practice. After the mid-term review, the glossary was updated to include more words and meanings were confirmed though back-translation. Words in Dinka and Luo were also added to the Sick Child Job Aid where there were English words.
• In planning the project's activities, including training implementation, the initial work plans developed did not account for all of the resources (technical support, numbers of training teams, logistics, procurement timelines etc.) that were required to roll out the training. This needed to be at a sufficient scale to reconcile the heavy technical MoH guidelines with very low levels of literacy. In this situation, embedding continuous learning and improvement is critical and should be accommodated for in work planning."

According to the paper, this experience shows that adaptation of materials is a resource intensive, proactive, and on-going process, which requires testing existing best practices and evaluating which systems, methodologies, and tools can be used in various settings, as opposed to those that require additional revising or innovation.