Isangula et al. BMC Health Services Research (2023) 23:56 BMC Health Services Research https://doi.org/10.1186/s12913-023-09061-y RESEARCH Open Access Implementation of distance learning IMCI training in rural districts of Tanzania Kahabi Isangula1,2*†, Esther Ngadaya1*†, Alexander Manu3,4†, Mary Mmweteni5†, Doreen Philbert1, Dorica Burengelo1, Gibson Kagaruki1, Mbazi Senkoro1, Godfather Kimaro1, Amos Kahwa1, Fikiri Mazige5, Felix Bundala6, Nemes Iriya7, Francis Donard1, Caritas Kitinya1, Victor Minja1, Festo Nyakairo1, Gagan Gupta8, Luwei Pearson8, Minjoon Kim8, Sayoki Mfinanga1, Ulrika Baker5 and Tedbabe Degefie Hailegebriel8 Abstract Background The standard face-to-face training for the integrated management of childhood illness (IMCI) continues to be plagued by concerns of low coverage of trainees, the prolonged absence of trainees from the health facility to attend training and the high cost of training. Consequently, the distance learning IMCI training model is increasingly being promoted to address some of these challenges in resource-limited settings. This paper examines participants’ accounts of the paper-based IMCI distance learning training programme in three district councils in Mbeya region, Tanzania. Methods A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of the management of possible serious bacterial infection in Busokelo, Kyela and Mbarali district councils of Mbeya Region in Tanzania. Key informant interviews were conducted with purposefully selected policymakers, partners, programme managers and healthcare workers, including beneficiaries and training facilitators. Results About 60 key informant interviews were conducted, of which 53% of participants were healthcare work- ers, including nurses, clinicians and pharmacists, and 22% were healthcare administrators, including district medical officers, reproductive and child health coordinators and programme officers. The findings indicate that the distance learning IMCI training model (DIMCI) was designed to address concerns about the standard IMCI model by enhanc- ing efficiency, increasing outputs and reducing training costs. DIMCI included a mix of brief face-to-face orientation sessions, several weeks of self-directed learning, group discussions and brief face-to-face review sessions with facilita- tors. The DIMCI course covered topics related to management of sick newborns, referral decisions and reporting with nurses and clinicians as the main beneficiaries of the training. The problems with DIMCI included technological challenges related to limited access to proper learning technology (e.g., computers) and unfriendly learning materi- als. Personal challenges included work-study-family demands, and design and coordination challenges, including low financial incentives, which contributed to participants defaulting, and limited mentorship and follow-up due to limited funding and transport. †Kahabi Isangula, Esther Ngadaya, Alexander Manu and Mary Mmweteni contributed equally to this work. *Correspondence: Kahabi Isangula kaisa079@yahoo.com Esther Ngadaya engadaya@yahoo.com Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons.o rg/p ubli cdoma in/z ero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Isangula et al. BMC Health Services Research (2023) 23:56 Page 2 of 13 Conclusion DIMCI was implemented successfully in rural Tanzania. It facilitated the training of many healthcare workers at low cost and resulted in improved knowledge, competence and confidence among healthcare workers in managing sick newborns. However, technological, personal, and design and coordination challenges continue to face learners in rural areas; these will need to be addressed to maximize the success of DIMCI. Keywords IMCI, PSBI, Tanzania, MCH, Newborn deaths Introduction a problem in Tanzania [10–15]. While the country has Improving the capacity of healthcare workers (HCWs) to witnessed a rapid decline in under-five mortality, there provide essential newborn care services has been widely has been a much slower decline in deaths of newborns in recognized as a key entry point for reducing neonatal the first month of life [10]. The rate of mortality among deaths. Cognizant of this, the World Health Organization infants (children aged below 12 months) is 43 per 1000 (WHO), the United Nations Children’s Fund (UNICEF), live births [10], while the neonatal mortality rate (deaths and other partners have developed and supported the during the first 28 days) is 25 per 1000 live births and con- implementation of capacity building interventions for tributes to more than 50% of infant mortality. The major HCWs, including the integrated management of child- causes of newborn mortality in Tanzania include birth hood illness (IMCI) strategy [1, 2]. Further, WHO has asphyxia (31%), complications of prematurity (25%) and also developed a guideline on management of sick young infections (25%) [11], placing Tanzania among the top 10 infants with possible serious bacterial infection (PSBI) countries with the highest number (thousands) of new- when a referral is not possible. The implementation of born deaths in the world, and among the top five in sub- this guideline is documented as having the potential Saharan Africa [12]. A survey by Mangu [13] indicates to contribute significantly to saving infant lives [3–6]. that sepsis contributed to 29% of 26,630 newborn deaths Improving the skills of HCWs on both IMCI and PSBI is a documented between 2005 and 2015, with an increase in critical strategy for reducing neonatal deaths in resource- hospital-based neonatal mortality rates from 2.6 deaths constrained settings [1–5]. This highlights the need for per 1000 live births in 2006 to 10.4 in 2015. This indicates continued capacity building of HCWs in resource-limited that training of HCWs – to equip them with adequate settings to maximize their contribution towards prevent- knowledge and skills in identifying and timely managing ing newborn deaths. sick newborns – is among the key strategies for reducing IMCI training focuses on improving case manage- infection-related newborn deaths [6]. Cognizant of this, ment among HCWs, health system strengthening and UNICEF supported delivery of the DIMCI training dur- promotion of good practices at both the family and com- ing implementation of a pilot project for the management munity levels. Evidence indicates that the IMCI strategy of young infants with PSBI in Mbeya region of Tanzania has the potential to both improve the quality of care and for the past 3 years. prevent neonatal mortality [7, 8]. Despite its potential, As the PSBI project is ending, it was important to the standard face-to-face training model (a residential conduct endline survey to examine how the DIMCI 11-day training) has faced several concerns, including programme was implemented almost a decade after it poor trainee coverage efficiency; absenteeism of train- started in Tanzania (See, [2]). This paper therefore exam- ees from health facilities for prolonged periods of time, ines participants’ accounts of the process used to imple- which negatively impacts service provision; and a high ment the DIMCI training programme in Mbeya region. cost of implementation, especially in resource-limited The paper draws from the data collected as part of an settings [1, 2, 9]. Consequently, the distance learning endline evaluation assessment that sought to assess and IMCI training model (DIMCI) (10 weeks with only 3-day document the process used to implement the PSBI pro- face-to-face meetings among trainees and facilitators) is ject, the outcomes achieved, and the lessons learned to increasingly being promoted to address some of these inform recommendations for potential national scale-up challenges. based on the experiences of the three councils in Mbeya. More than 420,000 newborns die globally each year from serious infection. Most of these deaths could be averted by preventive measures, timely care seeking, Methods treatment with appropriate antibiotics and follow-up [6]. Design Newborns in Tanzania are not exempted from developing A cross-sectional qualitative descriptive design was signs of PSBI and requiring antibiotics. Evidence contin- employed as part of an endline evaluation study of ues to indicate that infection-related neonatal deaths are PSBI implementation in Mbeya Region of Tanzania. The endline evaluation took an implementation science Isangula et al. BMC Health Services Research (2023) 23:56 Page 3 of 13 approach, using mixed methods (qualitative and quanti- policy-level stakeholders and administrators (13) and tative) for data collection. The use of qualitative descrip- HCWs working in child health outpatient clinics (32). tive approach for this inquiry was deemed appropriate This made for a total of 45 key informant interviews and to answer three key questions: (1) How was the DIMCI in-depth interviews from the supply side. Contact infor- model implemented? (2) What were the achievements mation of national-level stakeholders was obtained from of the DIMCI model? and (3) what were the barri- the newborn and child health unit of the Ministry of ers encountered during implementation? A qualitative Health. Relatedly, contact information for Regional and descriptive approach is appropriate for this inquiry as district-level stakeholders, administrators and health- it aimed to develop an understanding and describe the care workers was obtained from the selected study sites’ implementation of DIMCI without testing an exist- regional and district medical offices. Then, courtesy ing theory [16]. This approach offered an effective way calls were made with potential participants to inform of gaining a deep and rich understanding of the par- them about the study and scheduling of the interviews ticipants’ perceptions and experiences of DIMCI in the considering the individual preference of time, date, and chosen context, as this may differ from other contexts venue for those agreeing to participate. From the demand in terms of culture, expectations and resources within side, 15 in-depth interviews were conducted with pur- health care settings. The qualitative data utilized for this posefully selected community health workers (10) and paper were collected between June and August 2021. exit interview clients (5), including mothers/fathers/ caretakers with infants aged less than 60 days. Contact Settings information of community health workers was obtained This endline study was conducted in three intervention from the facility management team where DIMCI has districts – Busokelo, Kyela and Mbarali district councils been implemented. Courtesy calls were made to inform – in Mbeya region. Mbeya region is one of Tanzania‘s them about the study and scheduling of the interviews 31 administrative regions and is located in the south- considering the individual preference of time, date, and west part the country. The regional capital is the city of venue for those agreeing to participate. Participants for Mbeya. Mbeya Region is bordered to the northwest by exit interviews were recruited through reproductive and Tabora region, to the northeast by Singida region, to the child healthcare clinics in the course of seeking routine east by Iringa region, to the south by Songwe region and care. Information about the study was communicated to Malawi, and to the west by Songwe region. The region mothers and caretakers of children with PBSI during the covers an area of 35,954 k m2 and has a total of seven dis- health education session. Those interested in participat- tricts. There are total of 21 health facilities in Busokelo, ing expressed their readiness to the research assistant 46 in Kyela and 56 in Mbarali district councils; all were and were interviewed after receiving care but before leav- included in the study. Each district has one district hospi- ing the facility. tal. During the PSBI baseline study, the workforce density in Busokelo was 10 health professionals per 10,000 peo- Data collection ple. Nurses (registered, enrolled and midwives) were the Before data collection, the research assistants were most available cadre, while a limited number of special- trained on the use of data collection tools and tech- ists were found in the regional and referral hospitals in niques pertaining to this study. The English versions of Mbeya. the questionnaire were translated into Swahili language, then translated back to English and checked for concep- Sampling and participants enrollment tual equivalence. A consultative process was employed, To document the process of implementation of the involving experts at the National Institute for Medi- DIMCI training programme under the PSBI project, cal Research and UNICEF, to generate and translate the sampling commenced with a purposive selection of the interview guides into Swahili. Such tools were pre-tested three districts in Mbeya region, as well as national level in a purposefully selected setting. After pre-testing,data officials and implementing partners. As noted above, collection tools were refined to ensure that they were all 21 health facilities in Busokelo, 46 in Kyela and 56 in ready for use in the actual data collection process. Close Mbarali district councils were included in the study. We and supportive supervision was done throughout data then conducted interviews with selective key informants, collection and analysis stages to ensure data quality. Both such as policymakers, partners, programme managers in-depth and key informant interviews were conducted and HCWs (including beneficiaries and facilitators of the in a quiet and isolated room entirely disconnected from training programme). More specifically, interviews using regular activities. The audio-taped interview data were the DIMCI key informant interview guide were con- gathered using a flexible interview guide with topics on ducted with purposefully selected national and district distance learning IMCI, including socio-demographic Isangula et al. BMC Health Services Research (2023) 23:56 Page 4 of 13 characteristics of the respondents, recruitment process, to implementation of DIMCI throughout data collec- minimum qualifications, course content, structure and tion and analysis, without viewing it through an exist- organization, learning and training approaches, mentor- ing theoretical framework. Investigating DIMCI this ship and supervision, follow-up and course duration and way positioned our research within the constructivist schedule, job aids and beneficiaries. Perspectives of poli- paradigm, relying on participants’ descriptions to exam- cymakers, partners, programme managers and HCWs ine their perceptions and experiences of participation in (including beneficiaries and facilitators of the DIMCI the DIMCI in this specific context, rather than assuming training programme) were also examined. Prior to inter- it to be a positivist concept with a universally accepted views, each participant was given an information sheet framework of inquiry [17]. Future studies may consider a and a verbal description of the project in Swahili. Writ- theory-driven inquiry in a similar context. ten or verbal consent was obtained or recorded respec- tively. Each key informant interview lasted approximately Results 60 minutes. Participants’ sociodemographic characteristics This paper examines the data from qualitative interviews Data management and analysis with 60 participants. Of the 60 participants, 53% were During the training, project staff provided qualitative healthcare workers (nurses, clinicians and pharmacists); data collectors with digital recorders which they used 22% were healthcare administrators (district medical to record, listen to and transcribe the interviews in Swa- officers, reproductive and child health coordinators and hili. They then sent the transcriptions to translators, who programme officers); 17% were community health work- translated the Swahili language into English in prepara- ers; and 8% were mothers of young infants with PSBI. tion for data analysis. Project staff saved the transcrip- tions – both the Swahili and English language versions Key themes and subthemes – on password encrypted hard-drives or flash drives. The results were heuristically grouped into three themes, The initial analysis adopted a deductive ‘framework namely: feasibility of DIMCI, efficacy of DIMCI, and analysis’ approach for identifying themes and subthemes cost efficiency of DIMCI. To consider feasibility, we related to the research questions posed. The first stage of examined issues related to course structure and organi- analysis involved reading through the transcripts to iden- zation, course beneficiaries, course contents, course tify themes and subthemes and derive codes for subse- delivery, mentorship, supportive supervision and fol- quent stages of open and then axial coding. These steps low-up, and availability of job aids. We then compared broke down the qualitative data into units of analysis, DIMCI with the standard IMCI training. To consider and through this analysis researchers identified patterns efficacy, we examined participants’ descriptions of the and relationships, which elucidated the processes iden- success of DIMCI implementation. Finally, to consider tified in the research questions. Explanatory matrices cost efficiency, we examined issues related to the cost of were then developed in relation to each theme, drawing implementing the DIMCI programme. These issues are on the patterns. The research team used a consensus- examined in detail in subsequent sections. based approach to decide on including codes that did not fit within the pre-developed subthemes and themes; the Feasibility of DIMCI codes were excluded when they did not provide critical Findings related to feasibility of DIMCI were sevenfold. value to the study, as confirmed by subjective and objec- The first issue related to feasibility of DIMCI from the tive evaluations. This was followed by a collation of all implementation standpoint was course structure and relevant coded data extracts within identified themes. organization. Project documents indicated that front- Peer consultation was ongoing throughout the analysis line health workers were trained through a 10-week dis- process, as the research team reflected on the codes and tance learning course that consisted of three face-to-face themes generated. Coded data within NVivo were then meetings (facilitators and trainees) and two self-learning exported to Microsoft Word (Microsoft Corporation) periods of 5 weeks each. The face-to-face meetings con- for interpretative analysis and report generation. Par- sisted of both classroom and clinical practice sessions in ticipants’ accounts related to DIMCI were used for this a nearby facility. During qualitative interviews, partici- paper. pants described the DIMCI course as including a brief As noted above, the research team did not use a face-to-face orientation session, several weeks of self- theoretical framework; rather, participants’ descrip- learning, group discussions within the facilities and/or tions of DIMCI were examined by considering train- neighbouring facilities, and brief face-to-face examina- ing implementation in a specific context. This strategy tion and review sessions. The complete training package allowed a contextualized exploration of issues related was described as running for 10 weeks, with flexibility I sangula et al. BMC Health Services Research (2023) 23:56 Page 5 of 13 allowed in the schedule. The training schedule appears before referral, and what to do if someone refuses referrals. to have been pre-determined by the facilitators, while They were therefore trained on complete management, a consensus -building strategy was applied for the self- dosage and duration, filling the tools and using electronic study and group discussion component after orientation. system in general. (Health administrator, Kyela). As a staff member from the Ministry of Health described: The third issue related to feasibility of DIMCI was the (DIMCI) runs for 10 weeks. [Participants] study for course beneficiaries. The project committed to training 5 weeks, come for the review session, then do five more nurses and clinicians, specifically those working at the weeks and come again and do the exam, which results in dispensaries and outpatient department of health cen- being awarded a certificate. There are three phases. They tres and district hospitals through DIMCI, as they are have 1 day for orientation, then they are given modules directly- involved in newborn care in these facilities. Pro- for self-reading. The orientation day includes the mean- ject documents indicated that a total of 430 health work- ing of DIMCI and the guidelines they will use; they are ers (covering 80% of eligible primary health care health given DVDs, guidelines and other materials covering sev- workers) were trained from 174 health facilities (100% eral days [of the training]. Before they leave, they are put of health facilities in the project districts at the time of into study groups because there are days for self-reading training). Qualitative interviews indicate that nurses and for group discussions. The group discussions have a and clinicians (clinical officers, assistant medical officers chairperson. They develop a learning schedule and decide and medical doctors) were the main beneficiaries of the on topics for individual learning and group discussions. DIMCI training. The participant selection was described There are also groups for watching DVDs because we know to be conducted by the district IMCI focal person follow- some people residing in rural areas do not have TVs and ing criteria set by the Ministry of Health. The selection some have no laptops, or don’t know how to use laptops. criteria were based on cadres, primary responsibilities, That is why they plan among themselves. (Ministry of level and ownership of facilities and areas with high Health staff member) numbers of young children. At least two participants The second issue related to feasibility of DIMCI was were selected from dispensaries, including in-charges, course content. The DIMCI training manual indicates nurses and in some, medical attendants. During quali- the course contents as including: identification of signs tative interviews, the percentage of facilities in which such as fever, breathing rate, cough, diarrhoea, and ear HCWs participated in the training emerged as high, with problems; classification of severity of newborn based on some participants citing coverage ranging from 80% in their signs; management of identified newborn illness; Busokelo (reported by a trained HCW), 90% in Kyela education of mothers on home-based care and treat- (reported by a trained HCW) to 98% in Mbarali (reported ment; close follow-up of sick infants and documentation by a health administrator). In Mbarali for example, 119 and reporting. During qualitative interviews, the con- HCWs were cited as trained on DIMCI, although the tents of the DIMCI training were described as focusing target was 300. It is important to note that the reasons on management of diseases of young children, including for not reaching the target were not clearly unpacked in identification of danger signs, assessment and classifica- qualitative interviews: tion of severity using chartbooks, treatment and report- We looked at cadres considering nurses and doctors ing. Specific newborn diseases covered included bacterial according to the guideline, but most came from dispen- infections, diarrhoea and malaria. Decision-making was saries because they are highly engaged in referrals. In also covered, including referral decisions and initial man- all, we had 119 participants, although the target for the agement before referrals (e.g., dosage), as well as use of training was 300, because some faced different challenges reporting tools and electronic system. Some participants that limited their participation. Therefore, we had facil- commented: ity in-charge nurses and other nurses, but there are some The IMCI training focused on diseases affecting young facilities in which medical attendants participated. We children, how to detect and investigate them, how to clas- also had at least 1-2 participants from private facilities sify them as very severe, severe or not severe, and also that offer outpatient care. We concentrated more on areas treatment. We were also trained on how to use chart books where we could get many young children. (Health admin- for classification and filling the reports. (Trained HCW, istrator, Kyela). Mbarali). Since the project primarily deals with reproductive There were topics on classification of young children, issues, most of the participants selected are those who are topics on diarrhoea, malaria and other diseases affecting engaged in reproductive issues, including nurses. Each newborns, but also classifications of severity. There were facility produces about two participants working in repro- also topics on management after classification, deciding ductive health. We have 58 facilities, but two facilities are on the need for referral, the services that must be offered new. Therefore, about 98% of all facilities participated Isangula et al. BMC Health Services Research (2023) 23:56 Page 6 of 13 except new facilities, which had not been established when through WhatsApp and direct phone calls. Others we developed the plans. (Health administrator, Mbarali). mentioned brief face-to-face assessment and review The fourth issue related to feasibility of DIMCI was assessment sessions after the participants had under- course delivery. During qualitative interviews, as noted taken the assigned self-directed modules. In addition to above, the delivery of DIMCI was described to include assessments, the brief face-to-face review sessions with a mix of brief face-to-face orientation and review ses- facilitators were cited as including discussion on chal- sions, self-learning and group discussions. During brief lenges encountered during self-directed learning and face-to-face orientation and review sessions, DIMCI clinical practice and distribution of additional modules. content was presented via presentations and demonstra- One participant commented: tions by facilitators, group discussions and assignments, [Facilitators] came for follow-up after a certain time and homework. Participants who described self-learn- where they came to administer exams based on the mod- ing mentioned being given course modules, IMCI chart ules we were given. For example, if we were given five booklets, educative CDs/DVDs, IMCI photographic modules, we were required to read them and answer the books, logbooks containing IMCI recording forms, and questions. When they came, they would ask for the assign- exam sheets. They further described meeting for group ments for marking and feedback. They asked about the discussions, using the WhatsApp messaging platform for challenges encountered on the modules and we discussed learning, as well as phone calls with facilitators for sup- them together. Then they gave more modules for read- port when needed. Phone communication with facilita- ing and responding to the questions, as well as the date tors was a concern because participants were responsible for the next face-to-face session. (Health administrator, for the costs involved. This may have somewhat lim- Busokelo). ited the frequency of calls, although such affirmations The sixth issue related to feasibility of DIMCI was did not specifically emerge in the data. One participant availability of job aids. When asked about job aids, most commented: participants cited learning materials such as modules, [Facilitators]were sending us photos of sick children recording forms and DVDs. Likewise, child assessment recorded on CDs and we were also using books for reading and treatment decision-making materials, including and guiding treatments. To ensure that we were studying, IMCI chart books were noted. Additionally, reporting they gave us exams that were collected and marked every books or registers were reported to be offered by the time we met. Also, they gave us phone numbers for con- project. While some participants described pre-existing sultations whenever we faced any challenge, but we had working tools such as computers in their facilities, others to cover the cost of calling. There were study groups; each cited logbooks and guidelines as the job aids provided. It group had a leader and we used to agree on a meeting is not clear whether participants were able to make full place for discussion on the cases using books and CDs. We use of these materials; however, assessment of the log- used to communicate through SMS on where and when to books during face-to-face review sessions was cited as an meet, and the agenda and discussion questions. We used a important monitoring strategy (see above).Regarding job computer to watch CDs (HCW, Mbarali). aids, one participant commented: The fifth issue related to feasibility of DIMCI was After finishing the training, I was given 13 books, includ- mentorship, supportive supervision, and follow-up. ing guidelines and logbooks. Each book described a certain Recognizing the importance of ongoing support after disease, such as diarrhoea and others. We were required the training, the Ministry of Health and partners devel- to read, answer questions, and fill out the logbooks for the oped the ‘Guideline for follow-up after IMCI training’. module that we had completed. (Trained HCW, Mbarali). This document provides guidance on key issues that They are given mother’s cards, charts books, 14 guide- need to be considered during follow-up after any IMCI lines and DVDs. (Ministry of Health staff member). training, with the purpose of reinforcing the new skills The problem with job aids, in particular the materi- gained by participants and solving problems encoun- als for self-learning DVDs, was inadequate facilities for tered in the course of implementing IMCI. A focus of viewing them, such as TVs and computers, concerns mentorship and follow-up is, therefore, case manage- about the durability of DVDs (and consequently recom- ment skills, health facility support (including availabil- mending that DVDs be converted into flash discs), and ity of essential drugs and commodities for child health), language barriers, with some recommending translation and documentation and reporting of services offered. into Swahili for consumption even with low staff cadres. When asked about mentorship, supportive supervision, However, concerns about the cost of converting contents and follow-ups during the DIMCI programme, mixed into flash disc were likewise highlighted as a potential descriptions emerged. Some participants described limitation to this recommendation. Some participants phone-based mentorship and follow-up by facilitators commented: Isangula et al. BMC Health Services Research (2023) 23:56 Page 7 of 13 Some of us failed to answer the questions because they Resources used for distance learning cost less than those did not have facilities to watch the DVDs, and some for face-to-face training because when you invite people encountered problems in using DVDs. (Trained HCW, into a classroom you have to prepare notebooks, pens, pay Mbarali). for venue, food and transport. (Trained HCW, Busokelo). There were some challenges with DVDs. People living On the contrary, another group, comprised of a few in rural areas take Bodaboda [motorcycle taxis] after participants, suggested that DIMCI may be expensive class, which makes it easy for DVDs to scratch and they compared with face-to-face sessions. The need for face- cannot be read afterwards [laughs]. Some do not have to-face orientation and review sessions, materials for self- TVs or electricity, meaning they may need to watch from reading and the time-consuming nature of DIMCI were a neighbour’s home, after incurring the cost of fuel for considered as the main drivers of cost compared with the generators. What they need to do is first convert them standard IMCI. This suggests that for the cost of DIMCI to flash discs and second translate DVDs into Swahili to be less than that of standard IMCI, the training would because they are in English, [a language] that people like need to be completely self-led, without any form of face- medical attendants are not conversant in. (Ministry of to-face interaction: Health staff member). I think distance learning may be expensive compared The seventh and final issue related to feasibility was with face-to-face training because the latter runs and ends the comparison of DIMCI and the standard IMCI train- within a specific period. But distance learning involves ing. Qualitative interviews went further to explore par- meetings and being given assignments that you go and do. ticipants’ perceptions about the differences between Then you come together to look at what you learned indi- standard IMCI and DIMCI, with mixed views emerg- vidually and you are given the next assignments. There- ing. To better understand the comparison, we used fore, it takes longer than face-to face learning. (Trained heuristic criteria in describing the difference between HCW, Mbarali). DIMCI and standard face-to-face IMCI trainings. The The second comparison criterion is beliefs on retain- first comparison criterion is the cost perspective. Par- ing the knowledge gained. Maximizing knowledge reten- ticipants were asked about their perceptions on the tion is a critical aspect of any training; if effective, it can cost difference between the two models of IMCI train- reduce the need for frequent refresher trainings. Except ing. Looking across transcripts, disagreements emerged for a few participants who considered the two approaches regarding the cost of DIMCI compared with traditional equally effective (i.e., having the same quality and knowl- face-to-face training. Most participants appeared to be edge decay potential), many  considered standard face- unaware of the specific cost of DIMCI, but were able to-face IMCI as having a higher likelihood of retention to offer comparisons. The majority of participants of the knowledge gained compared with DIMCI. The believed that the cost of DIMCI was less than the cost perceived drivers of high knowledge retention were an of traditional face-to-face IMCI trainings, as face-to- opportunity to gain more knowledge by prolonged inter- face trainings would require costly materials, such as action with facilitators conferred by standard IMCI com- venues, per diems, transport and prolonged engage- pared with DIMCI. This was evident in the accounts of ment (i.e., number of days). DIMCI was therefore some trained HCWs who had first-hand experience with considered a cost-saving training approach by many DIMCI: participants, with one describing a cost reduction of 70 Learning through face-to-face has the potential to sus- to 75%. Although both types of training require facilita- tain knowledge for a long time. After all, a person study- tion and training materials, the fewer number of days ing face-to-face gains richer content and has more time required for face-to-face orientation and the ability to to learn more things from facilitators, compared with train many participants at once were considered as the distance learning. During face-to-face you interact and main cost-saving drivers of DIMCI: exchange ideas on many issues with facilitators, and you If we talk of resources, we consider cost reduction, which discuss with your fellows as well. The knowledge sticks is 70% in distance learning, but other processes, including in your mind for a very long time and you can use that having a teacher come to teach, are almost the same. (Pro- knowledge to work effectively (Trained HCW, Busokelo). gramme manager, Mbeya). On the contrary, some macro-level participants sug- The cost per [DIMCI] participant is around US$340– gested that DIMCI had more potential for knowledge 400, but previously, [with IMCI] it used to be $1000. retention than standard face-to-face IMCI. These asser- Therefore, the cost reduction is around 75% for DIMCI, tions were very common in the accounts of WHO staff, including training materials plus follow-ups, but the who drew these conclusions from their rationale for (IMCI) used to be $1000 without follow-ups. (Manager, developing the DIMCI programme or from their experi- Mbeya). ences in implementing the previous pilot project: Isangula et al. BMC Health Services Research (2023) 23:56 Page 8 of 13 After some time, skill retention was much better with Distance learning facilitates learners’ capacity to think DIMCI than with the standard IMCI because those in more critically and expand their thinking on their own, the standard scheme just went back after completing compared with trainings where you are taught everything. the course...but those in DIMCI had more time for self- Because in distance learning, imagine you meet a case, reading and practice because they were more commit- you must discuss among yourselves as providers, challenge ted. (WHO staff member). and correct one another until you reach current man- The third comparison criterion is the work-study bal- agement. [This is] unlike ‘spoon feeding’ in a classroom, ance advantage. Since the trained HCWs are employed [where] everything is taught by a trainer. (Health Admin- and working at healthcare facilities, a training that istrator, Kyela). allows participants to study while continuing their reg- IMCI did not build the culture of self-study and people ular work offers more work-study balance. Some partic- had lost motivation to study, but DIMCI built a studying ipants affirmed that DIMCI provided more work-study culture. You may find a facility has three to four staff and flexibility compared with the standard face-to-face they can study together and motivate each other. DIMCI IMCI learning. Work-study flexibility was considered has facilitated easy implementation because learning critical in maintaining the healthcare workforce at the occurs at the facility; therefore, a HCWs implements eve- facility, as it allows HCWs to fulfil their routine duties rything she or he studies at the same facility. (WHO, staff while studying. The standard IMCI was considered to member). offer less work-study balance because of the need for The fifth and final comparison criteria is the number of participants to attend trainings away from the worksta- beneficiaries. There was broad consensus among partici- tion for a long time, creating a workforce deficit that pants that DIMCI offered an opportunity for more peo- negatively impaired service provision: ple to learn at the same time, compared to the standard Personally, I think DIMCI is good because a provider face-to-face IMCI training. This indicates that DIMCI continues with normal work while studying. Assign- has the potential to reach more people than the standard ments and scenarios will be sent, the provider reads the IMCI, especially if no face-to-face orientation sessions reference books, responds, and continues working. Many are included. Furthermore, DIMCI was considered to facilities will remain empty if the contents are delivered offer more opportunity for skills practice because par- face-to-face and providers must attend (face-to-face) ticipants had greater access to sick newborns at their trainings, because the topics are very long, and they workstation during self-directed learning, compared with study for a very long time. Therefore, it will contribute limited interaction with cases during standard face-to- to a staffing deficit at the facility and impair services. face trainings: DIMCI is good because they study and continue offering Distance learning is very good because many people services. (Health administrator, Busokelo). get educated at the same time, instead of taking one per- [DIMCI came because] people were complaining son from the facility to go attend the training for seven or about the problem with face-to face training – that it 14 days. (HCW, Mbarali). requires taking a provider away from a workstation for During standard IMCI, it was difficult to get sick new- almost 2 weeks, meaning people were missing the ser- borns for practice; therefore, we ended with just demon- vices. That is why it was necessary to come up with a strations. But with DIMCI, they can access sick newborns modality in which the provider is taken away for a very at the facility every day and they were able to go to a short time, but receives the same content as if she or he nearby facility or visit them at home and they had more were taken for a long time. (National trainer of trainers). time to do assessments of young children. (WHO staff The fourth comparison criterion is the potential to member). allow reflective critical thinking. Aside from one par- ticipant, who considered both DIMCI and face-to-face Efficacy of DIMCI implementation trainings as having the same quality, some felt that Participants cited several successes arising from the DIMCI provided more opportunities for reflective application of the skills they had gained through the critical thinking on the content than standard face-to- DIMCI training programme, including: (i) improved face IMCI training. Self-learning in DIMCI was said knowledge among HCWs on IMCI; (ii) improved man- to allow for self-reflection among participants, while agement of under-five children due to improved knowl- the standard face-to-face IMCI was considered to be a edge and skills; (iii) improved quality of care and; (iii) form of ‘spoon feeding’ the contents. Some went fur- improved happiness among providers and service users. ther to suggest that DIMCI increased the motivation According to participants, increased happiness among for self-directed study compared with standard face-to- service users was largely influenced by reduced waiting face IMCI: time and improved friendliness of healthcare providers I sangula et al. BMC Health Services Research (2023) 23:56 Page 9 of 13 (detailed previously). Such improvements were highly without any problem. In short, the training has helped us linked to the DIMCI training; they not only contributed a lot; for example, if the doctor is not available, I can sit to reducing newborn and maternal deaths, but will likely and treat a baby without any problem. (HCW, Mbarali). continue reducing deaths of newborns and mothers in the future: The cost efficiency of the DIMCI programme Providers became very happy. Service users became Qualitative interviews went further to examine train- very happy. Services were accessible. Community health ing costs. Looking across transcripts, there was broad workers were available and working responsibly. We have consensus among participants that they were unaware reduced deaths to a large extent. (UNICEF staff, Mbeya). of the cost of DIMCI trainings. Most participants, such This project is very good. The project has brought many as trained HCWs and district administrators, such as successes, especially in offering care to under-five chil- district medical officers and district RCH cordinators dren. Most providers did not have a good understand- used phrases such as, ‘I cannot talk about it’ or ‘I don’t ing of the management of young children, but this has know the cost incurred’. Such statements suggest that improved after the distance learning, especially after the DIMCI budget may not have been shared with dis- learning through modules and practising afterwards. trict authorities and participants. However, few health They use chart books; they have the capacity to refer and administrators went ahead to mention cost items, such know what is needed. I believe in the next 10 years, deaths as per diems paid during a brief face-to-face DIMCI ori- among under-fives will be reduced significantly, because entation training (TZS 80,000 for each participant from even now, you can’t compare with what was happening the district). Other costs included transport refunds, before. (Health administrator, Mbarali). food, venue and stationery, particularly during the brief Another success cited by participants was improved face-to-face sessions within DIMCI training. One health confidence and capacity to identify and manage problems administrator approximated the cost of DIMCI to reach experienced by young children through a classification about TZS 27 million per session: process using chartbooks. This was the dominant suc- I cannot talk about the cost of training because I do not cess cited in relation to the knowledge and skills gained know how much the [PSBI] implementers used, but on our through the DIMCI training. Increased confidence in side, we paid a large cost, especially during participant managing newborn diseases among healthcare workers meetings with facilitators. (Health administrator, Kyela). was likewise linked to reduced newborn referral tenden- The cost per participant for the per diem at the district cies from low to higher level facilities compared with the was TZS 80,000. Transport was also refunded at about pre-project period. Furthermore, there was an affirma- TZS 10,000 each. I did not capture the full cost because tion of improved use of the IMCI guideline for manage- the activity was coordinated by Catholic Relief Services ment of childhood diseases. Increased use of the IMCI and UNICEF. But there were also food costs; I don’t know guideline among healthcare workers for treatment deci- how much they paid. There was also stationery, including sions may have contributed to improved management of notebook and printed papers. Also, they hired three ven- newborn diseases: ues, so almost TZS 14 million and TZS 40,000 may have One of the important benefits is increased confidence of been used per participant. We had seven facilitators; I healthcare workers in managing newborns. Before that, don’t know how much they were paid, but let us say they HCWs at lower levels were just referring newborns, even if got TZS 150,000 … they may have used TZS 9 million they had the capacity to manage. Therefore, DIMCI built each, making a total of around 27 million (Health admin- the capacity of HCWs to manage young children at low istrator, Mbarali). levels. (WHO staff member). Personally, the successes I have witnessed include chil- Discussion dren who met the criteria for severe diseases after using This paper describes the delivery of the DIMCI train- classification procedures. This has simplified our work ing programme during PSBI project implementation in because we do not need to use complex investigations to the three district councils in Mbeya region. We utilized detect problems that a child is suffering from. You just the data collected as part of an end-line evaluation that open your chart book and classify the baby based on the sought to assess and document the process used to imple- symptoms described by the mother. This has made it easy ment the PSBI project, the outcomes achieved, and the to discover the problems troubling the child and offer effec- lessons learned in the three councils to inform recom- tive treatment as part of IMCI. (Trained HCW, Mbarali). mendations for potential national scale-up. Qualitative The training was good. Initially, I did not know how to interviews were conducted with national, regional and recognize a child with pneumonia but now I can detect district stakeholders, including trained beneficiaries and him/her. I can treat the baby (with pneumonia) very well implementing partners, to generate an understanding Isangula et al. BMC Health Services Research (2023) 23:56 Page 10 of 13 of how distance IMCI was implemented. The study was DIMCI programme implemented in Mbeya was adapted constructed with the acknowledgement that prompt from WHO distance learning IMCI training curriculum identification and treatment of sick young infants (aged [18]. This further implies that the DIMCI was imple- 0 to 59 days) is key in reducing mortality and morbidity mented in Tanzania by adhering to global recommenda- [3–5]. While several interventions exist for the care of tions on implementing similar activities in low-resource sick newborns in healthcare facilities, newborn morbid- countries. ity and mortality remain challenges in Tanzania. As part of the response, UNICEF supported the Government of The delivery of the DIMCI: Structure, organization, Tanzania to implement a three-year pilot project in the contents, and beneficiaries Mbeya region applying the new WHO PSBI guidelines in Our findings indicate that the delivery of DIMCI involved primary health facilities to provide guidance on the use a face-to-face orientation session, several weeks of self- of simplified antibiotic regimens. As part of PSBI imple- learning, group discussions involving healthcare work- mentation, HCWs were trained using the DIMCI training ers within facilities and/or neighbouring facilities, and curriculum. The pilot project was constructed within the brief face-to-face examination and review sessions. The context of scientific evidence to the effect that implemen- course contents included topics such as identification tation of the WHO guideline on the management of sick of danger signs, assessment and classification of sever- young infants with PSBI when a referral is not possible ity using chartbooks, referral decisions and initial man- can contribute significantly to saving infant lives [3–5]. agement before referrals (e.g., dosage), and the use of Assessing the impact of the intervention, documenting reporting tools and electronic system. Therefore, a focus the process of implementation of the distance learn- on topics reflecting the major conditions contributing to ing IMCI programme and documenting the key lessons newborn and under-five mortality in Tanzania was criti- learned was therefore critical in offering recommenda- cal for maximizing the benefits of DIMCI. It is important tions that could inform scale-up both within and outside to note that infections, delayed treatment, and delayed the country. referrals have been previously documented as among the key contributors of newborn and under-five deaths in The origin of DIMCI in Tanzania Tanzania, despite notable improvements [13, 19, 20]. Fur- Examining its origin in Tanzania, the findings of the pre- thermore, research continues to indicate that frontline sent study indicate that DIMCI originated from stand- health workers have weaker capacity to provide quality ard IMCI because of the need to enhance efficiency and and timely maternal and newborn care in Tanzania, with deliver more cost-effective training courses. This need most needing additional training [21]. Therefore, a focus was fuelled by the desire to reduce training costs by on nurses, clinical officers, assistant medical officers, and reducing the number of days required for face-to-face medical doctors is a critical aspect of DIMCI because training, maximizing the number of participants using they are the first individuals to handle sick newborns limited resources, and reducing the prolonged absence in primary healthcare settings. The selection of these of HCWs at facilities during class-based IMCI trainings frontline healthcare workers was conducted by a district (leading to service delays). Low coverage of IMCI, its IMCI focal person in coordination with the reproductive high cost and the need for HCWs to be away from their and child health coordinator and the Ministry of Health, workplace for a prolonged period, have been previously partly because these people understand the capacity gaps documented as common shortfalls of the standard face- within the healthcare system. Taken together, these find- to-face IMCI training [1, 2, 9]. Distance learning IMCI ings imply that despite being delivered using a distance has been considered an innovative and low-cost alter- model, DIMCI was packed with topics that aimed to native for addressing these gaps in the standard face-to- enhance the capacity of frontline healthcare workers to face IMCI training [2]. This implies that delivering IMCI detect and manage newborns with PSBI in an attempt to through a distance learning model could be an impor- increase their survival. tant strategy for building the capacity of the healthcare The findings indicate that during the brief face-to- workforce without requiring travel away from the work- face orientation, DIMCI content was delivered via pres- station. These findings further indicate that DIMCI was entations and demonstrations by facilitators, group also influenced by the global movements on PSBI, includ- discussions and assignments, and homework. Self- ing global meetings for dissemination of recommenda- directed learning was delivered via course modules, IMCI tions for management of newborns. Consequently, local chart booklets, educative CDs/DVDs, photographic guidelines were reviewed, training modules and chart- books, logbooks and exam sheets. Our findings largely books were developed, and facilitators were trained with reflect what has been documented in previous literature a pilot in the three districts. This may explain why the on implementation of DIMCI in Tanzania [2, 21–23]. I sangula et al. BMC Health Services Research (2023) 23:56 Page 11 of 13 Muhe [2], for instance, documented DIMCI as consist- accommodate people who are unable to make use of the ing of three face-to-face encounters between IMCI train- materials. The second challenge was personal issues, ees and IMCI facilitators and two self-study periods such as limited time for self-study due to competing (3–4 weeks and 8–9 weeks) with self-directed learning for work and family responsibilities and language barri- 10–12 weeks for 4806 healthcare providers trained in 68 ers (with some recommending translation of contents districts in Tanzania. This indicates that, in low resources into Kiswahili). Competing priorities among HCWs has settings, brief orientation and follow-up sessions are been documented as a key challenge of implementing often needed on top of the self-directed learning, which IMCI in Tanzania [23]. Nevertheless, language barri- may pose significant costs for the delivery of DIMCI. ers suggest the need for translation of DIMCI materi- als into Swahili to ensure effective content delivery and The comparison between DIMCI and the standard IMCI absorption by HCWs within the country. The final chal- A comparison of DIMCI and the standard face-to-face lenge was design and coordination issues, such as low IMCI training model was carried out. Similar to the financial incentives and inadequate funds for mentor- standard IMCI, DIMCI is expected to include mentor- ship, supervision and follow-up. These challenges may ship and follow-up activities as part of continued sup- explain why there were mixed preferences for standard port for learners. Follow-up visits are expected to be and distance IMCI, with some people expressing pref- conducted 4–6 weeks after training to assess clinical erence for distance IMCI because of its relatively lower skills, reinforce clinical skills as well as provide sup- cost and its ability to offer better work-study balance portive supervision, solve supply issues and ensure and critical thinking, while others preferred the stand- reporting [2]. However, our findings indicate some ard IMCI because of the high possibility of knowledge weakness in mentorship and follow-up of HCWs after retention. Most of these issues have been documented the DIMCI training, with reliance on phone-based as common in other distance learning training models consultations with facilitators and peer group discus- focusing on HCWs in Tanzania and other low-income sions. It is important to note that lack of mentoring settings [27–29]. Taken together, these findings indi- and supervision from the tertiary level has been doc- cate that, although DIMCI may be less expensive than umented as one of the key barriers to implementation standard IMCI, there is a need to address the chal- of IMCI among HCWs in Tanzania [23]. While poor lenges of DIMCI by considering the technological, per- mentorship and follow-up after DIMCI training may be sonal and coordination barriers that HCWs in rural partly explained by inadequate funding and transporta- areas continue to face to maximize its success. tion after funding has ceased, this may have contributed to a preference for standard IMCI training among some The success of DIMCI implementation participants. This suggests a need for strengthening Despite the challenges observed, the findings indi- facility-based mentorship, supportive supervision and cate that DIMCI successfully facilitated the training of follow-up activities during and after DIMCI training. many healthcare workers, without jeopardizing patient The successful implementation of DIMCI may require management and at a low cost. DIMCI was linked to well-structured mentorship and follow-up activities. As improved knowledge among HCWs, and improved com- such, the budget for supportive supervision may need petence in the management of under-five children. Such to be increased for subsequent DIMCI implementation. improvement was regarded as more likely to reduce deaths of newborns and mothers in future, with some participants affirming that the training had contrib- The challenges of DIMCI implementation uted to a reduction in newborn deaths. Other successes Our findings indicate that the problems encountered included improved confidence and capacity to iden- during DIMCI implementation included technologi- tify and manage problems suffered by young children cal issues, such as inadequate facilities for personalized through the classification process using chartbooks, and learning (e.g., TVs and computers) and the non-dura- improved use of the IMCI guideline for the manage- bility of DVDs. Technological challenges have been pre- ment of childhood diseases. Similar findings have been viously indicated as limiting the capacity of both HCWs reported in previous studies. For instance, Muhe [2] and medical students to fully utilize the benefits of dis- reported that DIMCI allowed many HCWs to be trained tance learning courses in Africa [24–26]. This suggests in parallel and that HCWs trained in DIMCI performed a need to ensure access to relevant technology among equally well as those trained in the standard IMCI. These learners and the need for DIMCI materials to be avail- findings need to be considered with caution as increased able in multiple formats (e.g., DVDs and flash discs) to confidence and competence noted may deter HCWs Isangula et al. BMC Health Services Research (2023) 23:56 Page 12 of 13 at low-level facilities from providing timely referrals to Declarations some young infants with PSBI. Ethics approval and consent to participate The study was conducted in accordance with relevant local guidelines and Conclusion regulations. The study was approved by National Health Research Ethics Sub-Committee of the National Institute for Medical Research in Tanzania The DIMCI appears to have been implemented success- (Ethics Clearance Certificate No: NIMR/HQ/R.8a/Vol. IX/3710). Implementation fully in rural Tanzania. DIMCI facilitated the training of was made following permission sought from all relevant institutions at the national, regional, district, ward and village authorities including regional med- many HCWs at a low cost and resulted into improved ical officers, district medical officers, and managers of health facilities whereby knowledge, competence and confidence among HCWs in investigators submitted copies of the ethical clearance certificate. Informed the management of sick newborns. However, technologi- verbal consent was obtained from all research participants before participa-tion and recorded as part of the interview transcript and was approved by the cal challenges related to limited access to proper learn- National Health Research Ethics Sub-Committee of the National Institute for ing technology and language barriers for IMCI, personal Medical Research in Tanzania (Ethics Clearance Certificate No: NIMR/HQ/R.8a/ challenges including work-study-family demands, and Vol. IX/3710). We opted for informed verbal consent because it was deemed sufficient, as the study did not directly or indirectly expose participants to any DIMCI design and coordination challenges, including form of diagnosis or treatment. As safeguards, all participant responses were low financial incentives and limited subsequent men- made confidential, and data analysis and reporting were conducted at an torship and follow-up, continue to face learners in rural aggregated regional and district levels. Also, all data gathered were not used for purposes other than the present research. areas. These challenges will need to be addressed to max- imize the success of DIMCI. Consent for publication Not Applicable. Competing interests Abbreviations The authors declare that they have no competing interests. CD Compact disc DIMCI D istance learning on the integrated management of childhood Author details illness 1 National Institute for Medical Research-Muhimbili Centre, Dar es Salaam, DMO District medical officer Tanzania. 2 Aga Khan University, Dar Es Salaam, Tanzania. 3 University of Ghana DVD D igital versatile disc School of Public Health, Accra, Ghana. 4 London School of Hygiene and Tropi- HCW H ealthcare worker cal Medicine, Keppel Street, London, UK. 5 UNICEF Tanzania, Dar es Salaam, IMCI I ntegrated management of childhood illness Tanzania. 6 Ministry of Health, Dodoma, Tanzania. 7 World Health Organization, NIMR National Institute for Medical Research Dar Es Salaam, Tanzania. 8 UNICEF Headquarters, New York, USA. PSBI Possible serious bacterial infections UNICEF U nited Nations Children’s Fund Received: 2 June 2022 Accepted: 11 January 2023 WHO World Health Organization Supplementary Information The online version contains supplementary material available at https:// doi. 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