Given my experience as a teacher/trainer and as someone who has traveled the journey into profound deafness, the World Health Organization (WHO) asked me to develop a set of training resources for use in low and middle income (LMI) countries, gearing the materials toward those working with hard of hearing and deaf children and adults globally.
This project was an exciting prospect for me, as it involved focusing on communities, getting them to take ownership of problems and solutions, and empowering them with the essential knowledge and skills to prevent and manage ear and hearing issues. The inclusion of local healthcare workers, teachers, families, and members of the community was essential to guaranteeing sustainability of the approach.
It quickly became evident that just one level of training resource would not reach all levels of the health system and society at large, and so three levels of the WHO Primary Ear and Hearing Care (PEHC) Training Resource were developed.
In developing the materials, we were trying to ensure that not only healthcare workers but also communities were empowered to implement best practices at many levels, including in homes, schools, and the community itself.
TRAINING THE TRAINERS
In order to produce a generic global training resource, the Delphi technique was used, which administers questionnaires to a group of experts and shares feedback on the collective responses between questionnaire series, allowing participants to reevaluate their earlier answers and arrive at a consensus. An advisory committee was set up that included two ear, nose, and throat (ENT) specialists and an audiologist, an education expert, and a director of a society for deaf and hard of hearing people.
In the initial approach to training the trainers for work in low and middle income countries, a small number of facilitators was first trained over one to three days. Then, the delivery of training to groups of primary healthcare workers was observed. While this method was of some benefit, there was little to no follow-up of successful and sustainable projects within a given country.
For example, at the PEHC launch in Nairobi, Kenya, only two hours were spent on a presentation and discussion explaining the outcomes-based approach to delivering the necessary knowledge and skills for ear and hearing care. While representatives from seven Central African regions participated, no one monitored if or how the training was rolled out in the communities.
At the launch at the National Ear Care Center in Kaduna, Nigeria, four ENT specialists elected one-day training on the implementation of PEHC participant training for nine different provinces. Our approach was to observe and support the participants’ training.
This method was more successful. Over the next four or five years, we received e-mails from various provinces telling us how many healthcare workers had received the train-the-trainers program. We achieved this positive result by working with local health personnel at the National Ear Care Center.
FOCUSING ON OUTCOMES
Since that time, however, the approach has become even more sophisticated. One of the most successful training programs was recently held in Ndola, Zambia. Working with a nongovernmental organization (NGO), 27 participants from various levels of healthcare, teachers of the deaf, and volunteer group members were trained over five full days.
Expected outcomes for the program were developed in conjunction with four clinical officers working in the adult and children's hospital in Ndola. Discussions held during the months prior to training ensured common understanding of the needs of the local healthcare workers, teachers, and communities in relation to ear and hearing care.
The inclusion and participation of people with ear and hearing care problems in this five-day training program ensured ownership and partnership among their families and employees, as well as within schools and organizations.
One of our core principles was a move from the “chalk-and-talk” education approach to an outcomes-based learning system, which is critical to the sustainability of training in this area.
If participants are not focused on outcomes, then they will be less inclined to tailor approaches to the local culture and circumstances, and the advocated practices will quickly lose their meaning.
We received refreshing and positive feedback from the participants. Their comments showed that they had taken co-ownership of the challenges of managing ear and hearing issues, and focused on addressing them. It was evident that they had learned the essential messages and developed the skills for tailoring delivery mechanisms to the needs of their particular audiences.
By working together as a group and in smaller units, they exchanged information and identified possible actions that would benefit their communities. Simple solutions for sensitizing their communities were shared, such as the use of the local drama group to put on a play raising awareness of common ear disease and how to prevent it.
This project will be rolled out using a three-tier approach and will be evaluated at the end of the life of the project (one year).
ACCOUNTING FOR DIFFERENCES
In southern India, the WHO Primary Ear and Hearing Care resources also have been used to good effect. Various levels of healthcare and community workers have been prepared to roll out training programs, including the training of mental healthcare workers in rural villages.
The project coordinators have developed an appropriate approach to training that takes into account cultural and other differences between their communities. Training resources were translated into the local language, and parents and family members have attended workshops on how to include, educate, and communicate with their hard of hearing or deaf family members, which has had a positive impact on local communities.
In an unexpected and exciting outcome, members of the cardiac department at St. John's Medical College in Bangalore, India, were so impressed by the approach used in the WHO PEHC resources that they are adopting it as a model for the development of their own training program. This change required a shift of mind-set, which has resulted in more effective delivery of services and support for cardiac patients.
The opportunity to work with NGOs has allowed us to reach primary healthcare workers, teachers of the deaf, families, and communities. By coordinating with existing programs and organizations, we have learned that the principles of best practices remain strong, regardless of setting. These practices are just as valid in low or middle income countries as they are in wealthier countries.
Working in partnership at all levels is vital to guaranteeing the successful delivery of training and the rollout of sustainable best practices, to raising awareness in communities, and to ensuring inclusion of hard of hearing and deaf people in all sectors of society, such as places of education or employment.