Rethinking training for low literacy audiences

Kim Ethier Stover

Senior Improvement Advisor, USAID ASSIST Project/URC

Beginning in 2010, as part of my role as Senior Quality Improvement Advisor on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), I led the staff in building capacity of quality improvement teams in 51 rural communities in Ethiopia. In addition to building the capacity of quality improvement teams, we needed to develop the capacity of district and health center staff to support community-level quality improvement teams.  The challenge was that quality improvement team members had low levels of literacy or were illiterate.  Therefore, we were required to rethink the way that we approached improvement training.   

The first step was to break our reliance on PowerPoint slides and large amounts written materials which required reading and would only alienate part of our audience. Although I have always used a lot of adult learning approaches in training, it required some brainstorming to figure out how to turn explanatory presentations into accessible information for our audience.  This also took some trial and error (our own PDSAs!).  Although we had developed detailed facilitators’ notes and plans for the sessions, we weren’t afraid to redirect mid-course if an exercise or discussion was failing to convey the message.  We conducted our original training once for each region, so we were able to improve our approach between trainings.  

MaNHEP Training Program

Frontline health workers demonstrate maternal and newborn care practices as part of MaNHEP’s Community Maternal and Newborn Health training program.

After failing to convey some concepts of the improvement approach, the Ethiopian staff members of MaNHEP came up with a brilliant drama to portray the process and spawn discussion.  The drama focused on improving crop yield in Amhara and on improving milk yield from a cow in Oromiya and included an aim, measure and different tests of change. The discussion following allowed us to make the leap to improving care for moms and babies.  

Another big challenge was explaining indicators, measurement and time-series charts.  In the end our approach was to introduce these concepts and skills as they were needed.  We began with discussing the importance of measurement for improvement and what information they should collect.  At the next learning session, after teams had a few months of data, we taught them how to calculate percents and graphically display the numbers on a time series chart.   Analysis was an ongoing conversation at coaching visits and learning sessions from that point on. Later, we had to spend some time with coaches reviewing the difference between improvement and month to month variation to build their abilities to work with teams.  

We built the capacity of coaches through a combination of the basic improvement training, an additional day of training on facilitation and coaching, and ongoing mentoring from MaNHEP staff and experts. MaNHEP Coaching Tools is a compilation of tools designed to guide new coaches in providing support to quality improvement teams.

We didn’t develop the magic bullet for training improvement concepts, but our own improvement cycles around training resulted in some good ideas and sessions, summarized in MaNHEP Quality Improvement Training for Teams and CoachesRead more about building capacity for improvement and the results of this project.

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