Evaluation of the Impact of Immunization Second Year of Life Training Interventions on Health Care Workers in Ghana

"HCWs reported spending more time communicating with caregivers about vaccination and addressing their concerns."

The World Health Organization (WHO) recommends a second dose of measles-containing vaccine (MCV2) in the second year of life (2YL). Thus, in 2015, the United States Centers for Disease Control and Prevention (CDC) collaborated with Ghana Health Service (GHS) to implement multifaceted 2YL interventions, including training of trainers (TOTs) workshops with regional and district health management teams (DHMTs). This evaluation investigated whether frontline healthcare workers (HCWs) reported or demonstrated improvements in knowledge, attitudes, and practices - including on communication with caregivers - after training interventions.

GHS and CDC conducted TOT workshops from July through September 2017 for regional health management teams (RHMT) and DHMTs in 15 districts of 3 of the most underperforming regions with respect to MCV2 coverage: Greater Accra Region, Volta Region, and Northern Region. DHMTs implemented several capacity-building activities, including health facility visits, on-the-job training, and review meetings. The DHMTs used a variety of adult learning principles and delivery techniques to facilitate learning, including the application of performance improvement strategies (e.g., group problem analysis, supervisory and interpersonal skills). The training focused on 3 core competency areas:

• Expanded Programme on Immunization (EPI) policy - e.g., preventing missed opportunities for immunisation and managing adverse events following immunisation;
• Immunisation data management, recording, and use - e.g., accurately documenting data in tally books, child welfare clinic registers, child health record booklets, and monthly vaccination reports; and
• Communication with caregivers - e.g., increasing parents' awareness of MCV2 and addressing vaccine hesitancy.

A sample of 115 HCWs was selected to complete a competency survey before and 4 months after training. In addition, interviews and direct observations by data collectors were carried out to assess HCWs' knowledge, self-reported attitude, and behaviour changes.

Key findings:

• Modest but not statistically significant improvements were found in knowledge on EPI policy, immunisation data management, and communication skills with caregivers. The communication with caregivers' competency had the lowest increase in knowledge, with the mean score increasing by 2.2 points. Individual questions on what caregivers should expect from the 2YL visit and the importance of the 2YL intervention both increased by 0.77 points, and knowledge about addressing fears and vaccine hesitancy increased by 0.71 points.
• HCWs reported they had improved several attitudes and practices after the 2YL training. For example, HCWs described improvement in communication practices with caregivers during the vaccination visits due to the 2YL training. The HCWs said they are more patient with the caregivers and asked their clients for feedback on their one-on-one communication during immunisation sessions.

Reflecting on the findings, the researchers note that "'Success' for training interventions is determined by behavior change that leads to better outcomes and solves the performance problem. The evidence of knowledge growth as shown in... [the] quantitative results is supported by many of the qualitative comments from HCWs indicating positive behavior changes following the capacity-building interventions."

Selected implications include:

• National and subnational leaders should take ownership of the capacity-building needs of their immunisation workers and leverage existing mechanisms, such as new hire orientation, supportive supervision visits, and monthly data review meetings, to empower their HCWs to think of every health encounter as an opportunity to identify and reach children with recommended vaccines.
• The use of learner-focused teaching methods combined with adult learning principles was helpful in solving specific performance problems (such as lack of knowledge of EPI policy and poor documentation of data) and should be included as a standard practice for future training interventions.
• HCWs in Ghana and beyond could benefit from standardised, simple, high-quality job aids for immunisation topics that could be translated into many local languages.
• Countries should value budgeting for capacity-building of their immunisation workforce and for behaviour change evaluation to ensure an accurate understanding of capacity-building impact.

In conclusion: "With continued mentorship, peer-to-peer learning, and skill building through various means (e.g., supportive supervision visits or a buddy system), communication between nurses and caregivers will continue to improve over time. These improvements would lead to fewer missed opportunities for vaccination during the 2YL by capturing more unvaccinated children than in the past and ensuring they receive all appropriate vaccinations at the same immunization visit."