Every day at primary health centers across Nigeria, the Officer In-Charge (OIC) manages the routine immunization (RI) program, which ensures that hundreds of children under the age of one safely receive their required vaccinations at the right time.
The OIC’s role is dynamic. In addition to the management of all programs at the center, the officer must transcend the many challenges of vaccine management and delivery and ensure that they are stored and utilized appropriately to protect the community from vaccine-preventable diseases. To acquire the in-depth knowledge and skills to perform these multiple roles successfully, health care workers must receive training.
Historically, training involved long lectures in a classroom setting, over many years. Today, thanks to a new and innovative peer-led learning approach developed by CHAI and implemented at facilities across several states, workers are now able to receive more practical on-the-job training, more frequently.
Traditional training
Nigeria’s Expanded Program on Immunization (EPI) has increasingly become more complex. Within just the last five years, the number of vaccines on the EPI schedule has increased from six to nine, with plans to add even more. Additionally, the multi-dose vial policy has been revised along with changes in cold chain logistics. This means there is an increased need for well-trained, capable healthcare workers to manage RI programs effectively.
Traditional training involves text-heavy, impersonal lectures carried out in classrooms. This approach has limitations that affect the quality and efficacy of learning. Trainings are cascaded from the national level to state and lower levels, and can incur significant costs – about USD$20 to USD$50 per person trained per year. When cascade trainings do occur, there is often a high participant-to-trainer ratio, with an average of 50 participants per three trainers, preventing the individualized attention needed to facilitate learning.
This form of training can provide information overload for participants who spend long hours receiving largely theory-based lessons with little emphasis on practice and post-training supervision and evaluation to ensure that skills are retained. Further complicating the issue, there is hardly ever a plan to reach those health workers who do not attend training, creating a monopoly of knowledge for those who are able to attend. High worker attrition and transfer rates can also result in lost knowledge.
All of these challenges necessitated an innovative and cost-effective learning methodology designed and implemented for frontline healthcare workers.
A new approach to learning
In 2016, the Clinton Health Access Initiative (CHAI) conducted an Observatory Evaluation of Health Worker Practice (OEHP) to gauge the knowledge and skill level of healthcare workers. The assessment revealed an average competency level of only 65 percent when tested on effective immunization and vaccine management practices. Health workers received these low scores despite the significant number of traditional trainings carried out to build their capacity in this area.
To improve these poor results, CHAI worked with the government to try a new approach: onsite training and mentorship through peer-led learning programs.
Peer-led learning serves as an onsite refresher training for healthcare workers. Selected staff conduct bi-monthly, 30- to 60-minute sessions using job aids and other resources provided in the health facility. This interpersonal and interactive approach not only reinforces previous classroom training, but increases the frequency for practical learning opportunities among workers.
Peer-led training at the Primary Health Care Centre in Moroa of Kojona district in Northern Nigeria
One such onsite training program, Continuous Vaccine Management Education (cVME), was implemented by CHAI in Kano, Lagos, Nasarawa, and Rivers states between 2016 to 2017 to address the gap in knowledge and practice of healthcare workers. All health workers in the facility, including the OIC and the immunization program point person, took turns leading each session using simple training materials provided by the National Primary Health Care Development Agency (NPHCDA) in collaboration with CHAI. Each training session was documented in a logbook that included details on the participants who attended, the topic covered, and challenges encountered for follow-up.
During Routine Immunization Supportive Supervision (RISS), the regional supervisor reviewed the logbook and provided support and mentorship to healthcare workers onsite, addressing challenges and reinforcing immunization safety practices. The second round of OEHP conducted following the implementation of the peer-led learning approach showed an improvement in vaccine handling, vaccine administration, communication and advocacy, and data management practices of healthcare workers. In Kano, where the average competency score in 2016 was just 63 percent, it increased to 79 percent in 2017. Although this improvement might not be solely attributed to these new trainings, RISS spot checks revealed the peer-led learning approach has positively influenced vaccine management in health facilities.
Peer-led learning approaches can serve as a low-cost, sustainable, on-the-job refresher training for healthcare workers. At a cost of less than USD$2 per health facility, peer-led learning is more efficient compared to traditional training. As Nigeria’s EPI continues to push to increase vaccination coverage through effective routine immunization delivery, many other health programs will have the opportunity to leverage this transformative method of learning.
