MILDMAY UGANDA

BSc. (Hon)

HEALTH SYSTEMS APPROACH TO HEALTH andSOCIAL CARE

APROGRAME VALIDATED BY THE UNIVERSITY OFMANCHESTER UK

COURSE UNIT: 3

LEVEL-6

EDUCATION FOR CHANGE

Proposal: Initiating a Learning Resource Center(LRC) in Kiruhura District.

DATE OF SUBMISSION

17/06/2015

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Introduction(“Only the foolish learn from their experience — the wise learn from the experience of others.” Romanian Proverb)Family Health Resource Center (FHRC) a Non-Governmental Health Care Organization based in Kiruhura District with thirst to promote Evidence Based Health Care proposes the establishment of a Learning Resource Center (LRC) mandated to cause societal changes leveraging the strengths of Education and Training as contributors to the improvement of Health Care Practices, Health Care Policy, health Behaviour and Service delivery. The Center shall utilise the strength of Knowledge Translation (KT) as the main strategic approach in addition to Continuous Medical Education (CME), Continuous Professional Development (CPD) that are routinely used as educational and Training Approaches. It follows a Global as well as a local challenge that “health systems have failed to optimally use evidence with resulting inefficiencies and reduced quantity and quality of life” (Implementation Science report; 2011, DHO’s report 2013).

Locally, a Needs Assessment (NA) conducted in 2014 identified gaps in data generation and its use at community, Facility and District levels because data is sometimes unavailable or Health workers lack skills to utilise the available data. As a result Delivery of MCH services, Planning and allocation of resources isnot dependent on available evidence (Data) resulting into low coverage of such services (FP-18%, Deliveries under skilled attendance-32%, Exposed Children have continued to be Positive after DNA-PCR test).

In support of the above statement, American International Health Alliance (AIHA) 2003 paper on best practices wrote that “for health professionals to diagnose, treat, and prevent disease

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effectively, access to the most current research and information and attaining effective Training that facilitates Learning is critical”; “isolation from the ever-changing body of clinical research, practices become outdated and healthcare quality declines”. It is also known that, policy-makers, educators, and public health professionals can significantly improve their work by learning from the methodologies and practices of others (AIHA’s LRC model; Best Practices; 2003).

An adaptation from the American International Health Alliance (AIHA; 2002), the Learning Resource center (LRC) proposed shall be implemented in a phased manner and it aims at;• Increasing access to a vast wealth of evidence-based information resources derived from Health research, Clinical Audits, Data reviews in both virtual and in hard copy. • Serving as an Education and Training Center- a crucial vehicle for promoting the adoption of evidence based practice, Policy formulation i.e. Act as a Knowledge Hub.

Acting as Data Reference Hub for the 2 regions to aidresource allocation and service delivery for evidence-basedplanning, designing and Implementation.

It shall benefit Health Care professionals, Policy makers and theCommunities in Kiruhura District and the neighbouring Districts with the overall goal of improving quality Health Care services, strengthen Health Care System and improve quality of life of the citizens which is the mandate of Ugandan Ministry Of Health (MOH.It is expected that those allocating funding and those designing and running health services, as well as those delivering care to patients; use the most up-to-date information from health services literature, Clinical Audits and medical research backed by enough skills in knowledge Translation.

In order to promote the adoption of Evidence Based Health Care, build capacity of stakeholders in Health field the LRC shall walkthrough 4 programmatic areas;

1: Access to Health Resources,

2: Promotion of Evidence-based Practice,

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3: Service to Local Communities,

4: Support Telemedicine.

The LRC shall adopt the Knowledge Translation Cycle adapted from the Canadian Institute of Health Research (CIHR) as our guiding tool.

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Background

In Uganda and Kiruhura District in particular, a need for Health Care Organizations to dispense quality Health Care to their clients through improved Health Care Practices, health products and strengthened Health Systems exists. Gaps exist between what is known to improve Health and what is practiced to improve Health. Failure to follow best available evidence highlights issues of underuse, overuse, and misuse of Health Care resources and this challenge has led to widespread interest in Evidence Based Health Care (EBHC) so as to improve the safety of patients (Quality improvement Framework paper; 2011, Kiruhura District based NA;2014). As a result, Kiruhura District like many other Districts experiences shortfalls in the attainment of National Targets and the contributor to this may be lack of access to up-to-date Data and knowledge and skills to utilise the available data to allocate resources to where the greatest benefit can be realised or design and implement interventions that can yield greatest impact. The District has continuously underperformed in the National Health League (67th position as the best) without reaching even among the 1st 25 Districts. Services like FP and delivery under skilled attendance have continuously remained low(18% and 32% respectively) despite huge investment made by theImplementing Partners supporting the District.

The Health Affairs bulletin; (2014) highlighted that the practice of Evidence-Based Health Care (EBHC) is a new approach to Health Care delivery and it means conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It involves building Capacity of all professions associated with health care including; Physicians, Nurses, Allied Health Professionals, purchasing and management professionals. It is rooted in the Health Systems Strengthening approach that looks at the 6 Health Systems building blocks. It appraises the power of Information derived from Health Care Data,Clinical Audits and Health Research to improve the delivery of quality Health Care and promote accountability.

In support the above statement, an Evidence based Needs Assessment (EBNA) conducted in Kiruhura District in 2014 by B051405 Page 5

Mugume, demonstrated the knowledge and skills based gaps in data and Research Utilization to inform Clinical Practice, Policy Formulation and Implementation at all levels of health service delivery. A need to use information to accelerate the achievementof MDGs 4,5 and 6 was identified and the Health workers contactedthrough Questionnaire implementation and focused Group Discussions identified. A need to gain knowledge and skills in analysing data, synthesing it to generate information that can guide their Clinical Practice, programme design and effective service delivery.

Globally, attempts to reduce the gap between evidence and practice have existed and they include; educational strategies toalter practitioners’ behaviours and practices and Organisational and administrative interventions to create a conducive environment and directing resources to where there is a greatest need (BMJ: Learning in Practice; 2003).Educational strategies such as continuing medical education (CME), Continuing professional development (CPD) have continued to shape skills based trainings with some improvements but limited in the use of evidence to inform practice and change behaviour. Advances in thinking, Content and Context have led to the emergence of newest strategy - knowledge translation (KT) that attempts to improve knowledge and skills in Evidence Based Health Care sometimes referred to as “ Evidence Based Medicine”.

Below is a description of how knowledge translation differs from CME and CPD and why it is more effective in producing change. Knowledge translation reflects the considerations ofboth the practitioner-learner and the educational or clinical policy provider or healthcare system. This more holistic view makes it easier to close the gap between evidence and practice. On the other hand, Continuing Medical Education (CME) and Continuing Professional Development (CPD) are primarily teacher and learner driven and their ability to address questions of population health or attend to issues of clinical environment arelimited since both are predicated on a simple linear model linking learning to relicensing and recertification and only

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tangentially to performance or healthcare outcomes (BMJ: Learning in Practice; 2003).

In contrast, Knowledge translation offers a more holistic construct, building on the concepts of CME and CPD. Knowledge translation is set within the practice of health care and focuseson changing health outcomes using evidence based clinical knowledge. Knowledge translation can draw on people from many disciplines, including informatics, social and educational psychology, Organisational theory, and patient and public education, to help close the gap between evidence and practiceKnowledge translation both subsumes and broadens the concepts of CME and CPD and has the potential to improve understanding of, and overcome the barriers to, implementing evidence based practice (Crossing the quality chasm: Paper presentation: National Academy Press, 2001).

Knowledge Translation affirms greater use of Andragogy (art and science of teaching adults) as opposed to CME and CPD that utilize more of Pedagogy (art and science of teaching children-Teacher –Learner centered approach) by Malcolm Knowles.

Against this therefore, FHRC thinks that well-structured Educational and Training programmes that utilise Adult Learning methodologies to build capacity of Health Care professionals, policy makers, managers and the communities in both the science and practice of Knowledge Translation (KT) can propel the move ofevidence (new Knowledge) to Practice that is sometimes termed as “Knowledge to Action”.

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Literature Review.

Establishing the Kiruhura District based Learning Resource Center(LRC) follows a Global as well as a local challenge that, “some health systems are failing to optimally use evidence in the provision of Health Care with resulting inefficiencies and reduced quantity and quality of life” (Implementation Science report; 2011, Kiruhura District based NA, 2014) .

Related to the above statement, FHRC also recognise a shortage ofpeople trained in the science and practice of KT in Kiruhura District in particular and the neighbouring Districts necessitating the development of a regional training initiative in KT to enhance capacity in KT so as to effectively meet the needs of our Communities.

It is against this therefore why Family Health Resource center a Health Care Institution working to cause Change in the strengthening of Health Systems MUST invest in Education and Training of the stakeholders to Transfer the new Knowledge generated so as to improve the quality Health care provided (Knowledge to Action).

But before it is concluded to initiate KT programme, the writer wishes to highlight the role of Education and Training as change strategies to improvement of Health care services.

Don Berg (2008), wrote that “the tradition definition of education as merely the delivery of knowledge, skills and information from teachers to students is inadequate”. Inadequate because it does not make use of issues that enhance adult learning as stated by Taylor and Kroth ;2009; Self-Concept: adults are more self-directed ; Experience: more experiences to draw from as one matures; Readiness to learn: part of self-

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development; Orientation to learn: problem-centered learning; Motivation to learn: based on intrinsic motivation for goal attainment; The need to know: relevancy of subject to be learned.In his subsequent writings, he said “Education is a process of cognitive cartography, mapping your experiences and finding from a variety of reliable routes to optimal states”.

Education is said to be a continuous process, while training canbe undertaken for a limited purpose. Training is an Organized activity aimed at imparting information and/or instructions to improve the recipient's performance or to help him or her attain a required level of knowledge or skill, It(Training) is a learning process that involves the acquisition of knowledge, sharpening of skills, concepts, rules, or changing of attitudes and behaviours to enhance the performance of employees. It is about the acquisition of knowledge, skills, and abilities (KSA) through professional development (http://traininganddevelopment.naukrihub.com/training.html)

The above definitions and explanation of Education and Training concepts clearly show that the two cannot be separated and that both are crucial vehicles to performance as they stimulate personal growth and Development and facilitate Learning. The two (Education and Training) MUST be undertaken by any Organisation in need of a change in performance, practices and behaviour.

The explanations above can be affirmed by Benjamin Blooms Taxonomy which states that “knowledge is a pre-qualification to putting attitude and skills into practice”. Bloom’s Taxonomy is cognizant of the 3 domains of knowledge acquisition:

Cognitive-is Knowledge based

Affective- Attitudinal based

Psychomotor-is skills based

and that learning takes place in step-ladder form.

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In conformity to this, for the past 10years of working with the Local governments and Projects supporting Local Government it hasbeen noted that programmes like; STAR-SW, UPHOLD have failed to leave footsteps after the end of their contracts despite huge investments made in Training and Education of Health workers. Continuous Application of the theories learned has not taken place. But Literature reading on different models of Teaching (Pedagogy and Andragogy) have shaded light that may be the Training methods used were unable to improve Health Worker skillsbecause they would not facilitate Learning or were inappropriate to the level of Trainees; Most trainings were Pedagogical in nature other than Andragogical that is Learner centered where a learner determines the outcomes instead of a Teacher determining the outcome of the training. Up to this time, Kiruhura District’sHIV positivity among Children has remained high, services relatedto MCH have remained low(FP at 18%, Deliveries at 32%) despite availability of all resources to reduce the positivity rate and the Trainings (DHO’s report; 2014)

Supplementing the above experience, Bloom believed that “the educational objectives of learning range from surface level processing in which we simply acquire knowledge, through to deep level processing or critical thinking. The value of Bloom’s taxonomy is that it provides us with the type of learning

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activities we will need to engage in with our students in order to promote different levels of thinking across the continuum in order to facilitate Application, Analysis and Synthesis ( L. Herod,written 2002 and edited 2012)

Therefore, teaching and learning are best viewed as a continuum with pedagogy (directed learning) at one end, and andragogy (facilitated learning) at the other. It is suggested that in order for learning to be effective, tutors must move along this continuum based on the educational objective of the learning activity, as well as a number of other influencing factors like; Environment, Teacher, Trainee, self- Concept, Experience, Readiness to learn orientation, Administration (Malcolm Knowles; 1994).

In support of Bloom’s Taxonomy, Terehoff, (2002), Pohland & Bova,(2000) highlighted the importance of the “principal “as an instructional leader to create an environment that is conducive to the adult learner in addition to the “intrinsic” factors. Thismeans that as much as the environment is crucial for one to learn, “Administration” plays a very big role to creating this ample environment. This affirms what has been said that “education and Administration” play a crucial to the implementation of Evidence based Change programme

Understandably, learning is possible at any time but teachers, facilitators, mentors must be in cognizant of age of the learner,experience, intrinsic factors so as to design the best teaching methodology for that group for learning to take place. Programmesmust be designed to enable the learner put theory into practice so as to be a better performer and practitioner in his/her works.

Methodology:The LRC being proposed shall enhance capacity of stakeholder in the field of Health to advance the science and practice of KT by:1. Innovatively designing Education and Training programmes that promote Evidence Based Health Care through utilization of Andragogical methods of Teaching (CME, CPD and KT). Long and

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Short duration Programmes like; Health informatics, HMIS, Research methods, M & E shall be introduced to professionals working in the field of Health Care and others shall attract those without prior working experience(Direct entrants). 2. Linking trainees and mentors to collaboratively advance the science and practice of KT.3. Partnering with other national and international research groups Local community in order to move evidence into policy and practice through KT.4. Increase access to health Information derived from Health research, Clinical Audits and Data reviews.

To effectively implement the KT programme, the LRC shall utilize and follow through the knowledge creation "funnel" as defined andillustrated by the CIHR shown below.

The funnel above conveys the idea that knowledge needs to be increasingly distilled before it is ready for application.

Implementation Strategy/Plan:The pictorial below highlights the building blocks of our implementation plan (Capacity Building, Co-ordination and Collaboration) by creating demand for data use,collection of data, making data available and utilise data B051405 Page 12

generated to improve Health care delivery and Improve Health Systems.

Activities of this LRC shall be organized in 4 programme areas asfollows:

1: Access to Health Resources:• DEVELOP A PROACTIVE INFORMATION PROCESSING STRATEGY: Creation of new Knowledge thru Research, Clinical Audit.• DEVELOP AN INFORMATION DISSEMINATION STRATEGY- through virtual and hard copies (Journal and Publications

USE AVAILABLE SOFTWARE PRODUCTS WHEN APPROPRIATE ADAPT INFORMATION SYSTEMS TO INSTITUTIONAL PROCESSES

2: Promotion of Evidence-based Practice:Access to up-to-date information alone is often not enough to ensure meaningful changes in healthcare practices. Appraisal of the medical literature and improving the Knowledge and skills of Health Care Professionals is required. FHRC shall:• ESTABLISH AN ONGOING CAPACITY BUILDING PROGRAMME FOR QUALITYIMPROVEMENT• INTEGRATE EVIDENCE BASED PRACTICE (EBP) INTO EXISTING INSTITUTIONAL PROCESSES• PROVIDE EBP TRAINING TO STAFF• INVOLVE PATIENTS IN CARE DECISIONS• PROMOTE EBP THROUGH OPINION LEADERS

3: Service to Local Communities:B051405 Page 13

Family Health Resource Center shall promote giving back to community by;• INVOLVING THE LRC IN COMMUNITY HEALTH and HEALTH PROMOTION CAMPAIGNS• COLLECT and FACILITATE GREATER PATIENT INTERACTION • COOPERATING WITH LOCAL MASS MEDIA• TEAMING UP WITH LOCAL LIBRARIES• COLLABORATING WITH OTHER ORGANIZATIONS• DISSEMINATING INFORMATION THROUGH LOCAL GATHERINGS (COUNCILMEETINGS,WORKSHOPS and SEMINARS)

5: Support TelemedicineBy helping to disseminate the latest advances in health research,the rise of electronic communications has had a considerable impact on modern medicine. From simple e-mail-based requests to -live video consultations. The LRC shall play a critical role in helping health professionals reach out to the international medical community and in providing technical support for medical data conversion. The LRC utilise the following methods for an effective and efficient tele-consultations. • TRAIN STAFF TO DESIGN TELECONSULTATION REQUESTS PREPARED AHEAD OF TIME.• CONDUCT LITERATURE SEARCH PRIOR TO CONSULTATION

Objective:The LRC mandate is to improve the health of Ugandans, provide more effective health services and products and strengthen the health care system.

Specific Objectives: Train new and existing Health Professionals in the

Application of KT activities (synthesis,  dissemination,  exchange and ethically-sound application of knowledge) 

Generate New Knowledge and translate it into Policy and Practice through Knowledge Exchange to promote Leaning amongthe stakeholders (Knowledge Users, Decision Makers and Researchers).

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Continuously integrate science into routine Health service delivery so as to improve quality Health services and Strengthen Health Systems..

All these shall be geared at creating New Knowledge, Translate itinto policy and Practice through a dynamic and iterative process that includes;  synthesis, dissemination, exchange and ethically-sound application of knowledge.

Weren’t you supposed to come up with an action plan to show what and when you are going to do? If yes – add a brief detail on implementation and attach the plan

Monitoring and Evaluation:

FHRC shall utilise in built mechanisms to monitor and evaluate programme implementation as designed by the Organization. This shall be preceded by a Training Needs Assessment which shall act as baseline. Other routine methodologies shall follow Activity objectives and proposed outcomes. Midterm and End term evaluations shall be held to assess impact and outcome of training. Questionnaires targeting those who have undergone training shall shade light on theory-practice changes and significance of training or facility.

ConclusionTo be able to cause change in Health care settings and ultimatelyimprove the quality of services being provided, there is a dire need to invest in Training of Health Care professionals, Managersand Policy Makers in the Translation of new Knowledge to improve behaviour and Practice in the delivery of Health Care in Uganda. Designing and initiating an Education and Training programme targeting core Health workers and professionals who are known to use new Knowledge is a Smart thing to do and an investment itselfto improve Health Service Delivery.Training Health Professionals in KT is regarded as the best educational strategy to improve the Health needs of the communities because of its ability to use data, generate information and use this information to change practices, increase knowledge, increase understanding of the magnitude of

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the need by managers and policy makers, change behaviour and ultimately improve the quality of services provided.

References

Barer-Stein, T. & Kompf, M. (2001). The Craft of Teaching Adults. Toronto, Ontario: Irwin Publishing.

Bradley, Joe Bernard, Jr. Ph.D. Dissertation 2004, The Universityof Southern Mississippi)

Crossing the quality chasm: a new health system for the 21st century. Paper presentation: National Academy Press, 2001).

EBNA report; 2014; Institutionalizing Data and Research Use in Kiruhura District: Family Health Resource Center

Don Berg(2008),Defintion of Education and Training

L. Herod, EdD ,Written 2002; Updated February 2012 . ADULT LEARNING: FROM THEORY TO PRACTICE

Pohland, P., & Breda, B. (2000). Professional Development as Transformational Learning. International Journal of Leadership inEducation, 3, 2, 137-150.

Terehoff, I. I. (2002). Elements of Adult Learning in Teacher Professional Development. NASSP Bulletin, 86, 65-77. doi: 10.1177/019263650208663207

Terehoff (2002) and Pohland et al. (2000), Evauating persona proessiona Deveopment

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Taylor, B., & Kroth, M. (2009) Andragogy’s Transition Into The Future: Meta-Analysis of Andragogy and Its Search for a Measurable Instrument. Journal of Adult Education, 38, 1, 1-11.

American International Health Alliance(2008) Learning Resource Centers model; Linking Practitioners, Patients, and Communities to Vital Healthcare Information.BY KATHRYN UTAN

Applying Science to Strengthen and Improve Systems; August 2013 Version 2, September 2013 Version 3, February 2014; Kampala, Uganda.

Davis et al., (2003);Knowledge Translation Guide; shortening the journey from evidence to effect -The case for knowledge translation.

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Knowledge Translation Cycle: Adapted from Canadian Institute of Health Research

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