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PMC Articles

Implementation of distance learning IMCI training in rural districts of Tanzania

PMCID: PMC9854197

PMID: 36658537

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 workers, 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 enhancing 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 facilitators. 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 materials. 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. 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-023-09061-y.

Full Text

Improving the capacity of healthcare workers (HCWs) to provide essential newborn care services has been widely recognized as a key entry point for reducing neonatal deaths. Cognizant of this, the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and other partners have developed and supported the implementation of capacity building interventions for HCWs, including the integrated management of childhood illness (IMCI) strategy [1, 2]. Further, WHO has also developed a guideline on management of sick young infants with possible serious bacterial infection (PSBI) when a referral is not possible. The implementation of this guideline is documented as having the potential to contribute significantly to saving infant lives [3–6]. Improving the skills of HCWs on both IMCI and PSBI is a critical strategy for reducing neonatal deaths in resource-constrained settings [1–5]. This highlights the need for continued capacity building of HCWs in resource-limited settings to maximize their contribution towards preventing newborn deaths.
IMCI training focuses on improving case management among HCWs, health system strengthening and promotion of good practices at both the family and community levels. Evidence indicates that the IMCI strategy has the potential to both improve the quality of care and prevent neonatal mortality [7, 8]. Despite its potential, the standard face-to-face training model (a residential 11-day training) has faced several concerns, including poor trainee coverage efficiency; absenteeism of trainees from health facilities for prolonged periods of time, which negatively impacts service provision; and a high cost of implementation, especially in resource-limited settings [1, 2, 9]. Consequently, the distance learning IMCI training model (DIMCI) (10 weeks with only 3-day face-to-face meetings among trainees and facilitators) is increasingly being promoted to address some of these challenges.
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, treatment with appropriate antibiotics and follow-up [6]. Newborns in Tanzania are not exempted from developing signs of PSBI and requiring antibiotics. Evidence continues to indicate that infection-related neonatal deaths are a problem in Tanzania [10–15]. While the country has witnessed a rapid decline in under-five mortality, there has been a much slower decline in deaths of newborns in the first month of life [10]. The rate of mortality among infants (children aged below 12 months) is 43 per 1000 live births [10], while the neonatal mortality rate (deaths during the first 28 days) is 25 per 1000 live births and contributes to more than 50% of infant mortality. The major causes of newborn mortality in Tanzania include birth asphyxia (31%), complications of prematurity (25%) and infections (25%) [11], placing Tanzania among the top 10 countries with the highest number (thousands) of newborn deaths in the world, and among the top five in sub-Saharan Africa [12]. A survey by Mangu [13] indicates that sepsis contributed to 29% of 26,630 newborn deaths documented between 2005 and 2015, with an increase in hospital-based neonatal mortality rates from 2.6 deaths per 1000 live births in 2006 to 10.4 in 2015. This indicates that training of HCWs – to equip them with adequate knowledge and skills in identifying and timely managing sick newborns – is among the key strategies for reducing infection-related newborn deaths [6]. Cognizant of this, UNICEF supported delivery of the DIMCI training during implementation of a pilot project for the management of young infants with PSBI in Mbeya region of Tanzania for the past 3 years.
As the PSBI project is ending, it was important to conduct endline survey to examine how the DIMCI programme was implemented almost a decade after it started in Tanzania (See, [2]). This paper therefore examines participants’ accounts of the process used to implement the DIMCI training programme in Mbeya region. The paper draws from the data collected as part of an endline evaluation assessment that sought to assess and document the process used to implement the PSBI project, the outcomes achieved, and the lessons learned to inform recommendations for potential national scale-up based on the experiences of the three councils in Mbeya.
A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of PSBI implementation in Mbeya Region of Tanzania. The endline evaluation took an implementation science approach, using mixed methods (qualitative and quantitative) for data collection. The use of qualitative descriptive approach for this inquiry was deemed appropriate to answer three key questions: (1) How was the DIMCI model implemented? (2) What were the achievements of the DIMCI model? and (3) what were the barriers encountered during implementation? A qualitative descriptive approach is appropriate for this inquiry as it aimed to develop an understanding and describe the implementation of DIMCI without testing an existing theory [16]. This approach offered an effective way of gaining a deep and rich understanding of the participants’ perceptions and experiences of DIMCI in the chosen context, as this may differ from other contexts in terms of culture, expectations and resources within health care settings. The qualitative data utilized for this paper were collected between June and August 2021.
As noted above, the research team did not use a theoretical framework; rather, participants’ descriptions of DIMCI were examined by considering training implementation in a specific context. This strategy allowed a contextualized exploration of issues related to implementation of DIMCI throughout data collection and analysis, without viewing it through an existing theoretical framework. Investigating DIMCI this way positioned our research within the constructivist paradigm, relying on participants’ descriptions to examine their perceptions and experiences of participation in the DIMCI in this specific context, rather than assuming it to be a positivist concept with a universally accepted framework of inquiry [17]. Future studies may consider a theory-driven inquiry in a similar context.
This paper describes the delivery of the DIMCI training programme during PSBI project implementation in the three district councils in Mbeya region. We utilized the data collected as part of an end-line evaluation that sought to assess and document the process used to implement the PSBI project, the outcomes achieved, and the lessons learned in the three councils to inform recommendations for potential national scale-up. Qualitative interviews were conducted with national, regional and district stakeholders, including trained beneficiaries and implementing partners, to generate an understanding of how distance IMCI was implemented. The study was constructed with the acknowledgement that prompt identification and treatment of sick young infants (aged 0 to 59 days) is key in reducing mortality and morbidity [3–5]. While several interventions exist for the care of sick newborns in healthcare facilities, newborn morbidity and mortality remain challenges in Tanzania. As part of the response, UNICEF supported the Government of Tanzania to implement a three-year pilot project in the Mbeya region applying the new WHO PSBI guidelines in primary health facilities to provide guidance on the use of simplified antibiotic regimens. As part of PSBI implementation, HCWs were trained using the DIMCI training curriculum. The pilot project was constructed within the context of scientific evidence to the effect that implementation of the WHO guideline on the management of sick young infants with PSBI when a referral is not possible can contribute significantly to saving infant lives [3–5]. Assessing the impact of the intervention, documenting the process of implementation of the distance learning IMCI programme and documenting the key lessons learned was therefore critical in offering recommendations that could inform scale-up both within and outside the country.
Examining its origin in Tanzania, the findings of the present study indicate that DIMCI originated from standard IMCI because of the need to enhance efficiency and deliver more cost-effective training courses. This need was fuelled by the desire to reduce training costs by reducing the number of days required for face-to-face training, maximizing the number of participants using limited resources, and reducing the prolonged absence of HCWs at facilities during class-based IMCI trainings (leading to service delays). Low coverage of IMCI, its high cost and the need for HCWs to be away from their workplace for a prolonged period, have been previously documented as common shortfalls of the standard face-to-face IMCI training [1, 2, 9]. Distance learning IMCI has been considered an innovative and low-cost alternative for addressing these gaps in the standard face-to-face IMCI training [2]. This implies that delivering IMCI through a distance learning model could be an important strategy for building the capacity of the healthcare workforce without requiring travel away from the workstation. These findings further indicate that DIMCI was also influenced by the global movements on PSBI, including global meetings for dissemination of recommendations for management of newborns. Consequently, local guidelines were reviewed, training modules and chartbooks were developed, and facilitators were trained with a pilot in the three districts. This may explain why the DIMCI programme implemented in Mbeya was adapted from WHO distance learning IMCI training curriculum [18]. This further implies that the DIMCI was implemented in Tanzania by adhering to global recommendations on implementing similar activities in low-resource countries.
Our findings indicate that the delivery of DIMCI involved a face-to-face orientation session, several weeks of self-learning, group discussions involving healthcare workers within facilities and/or neighbouring facilities, and brief face-to-face examination and review sessions. The course contents included topics such as identification of danger signs, assessment and classification of severity using chartbooks, referral decisions and initial management before referrals (e.g., dosage), and the use of reporting tools and electronic system. Therefore, a focus on topics reflecting the major conditions contributing to newborn and under-five mortality in Tanzania was critical for maximizing the benefits of DIMCI. It is important to note that infections, delayed treatment, and delayed referrals have been previously documented as among the key contributors of newborn and under-five deaths in Tanzania, despite notable improvements [13, 19, 20]. Furthermore, research continues to indicate that frontline health workers have weaker capacity to provide quality and timely maternal and newborn care in Tanzania, with most needing additional training [21]. Therefore, a focus on nurses, clinical officers, assistant medical officers, and medical doctors is a critical aspect of DIMCI because they are the first individuals to handle sick newborns in primary healthcare settings. The selection of these frontline healthcare workers was conducted by a district IMCI focal person in coordination with the reproductive and child health coordinator and the Ministry of Health, partly because these people understand the capacity gaps within the healthcare system. Taken together, these findings imply that despite being delivered using a distance model, DIMCI was packed with topics that aimed to enhance the capacity of frontline healthcare workers to detect and manage newborns with PSBI in an attempt to increase their survival.
The findings indicate that during the brief face-to-face orientation, DIMCI content was delivered via presentations and demonstrations by facilitators, group discussions and assignments, and homework. Self-directed learning was delivered via course modules, IMCI chart booklets, educative CDs/DVDs, photographic books, logbooks and exam sheets. Our findings largely reflect what has been documented in previous literature on implementation of DIMCI in Tanzania [2, 21–23]. Muhe [2], for instance, documented DIMCI as consisting of three face-to-face encounters between IMCI trainees and IMCI facilitators and two self-study periods (3–4 weeks and 8–9 weeks) with self-directed learning for 10–12 weeks for 4806 healthcare providers trained in 68 districts in Tanzania. This indicates that, in low resources settings, brief orientation and follow-up sessions are often needed on top of the self-directed learning, which may pose significant costs for the delivery of DIMCI.
A comparison of DIMCI and the standard face-to-face IMCI training model was carried out. Similar to the standard IMCI, DIMCI is expected to include mentorship and follow-up activities as part of continued support for learners. Follow-up visits are expected to be conducted 4–6 weeks after training to assess clinical skills, reinforce clinical skills as well as provide supportive supervision, solve supply issues and ensure reporting [2]. However, our findings indicate some weakness in mentorship and follow-up of HCWs after the DIMCI training, with reliance on phone-based consultations with facilitators and peer group discussions. It is important to note that lack of mentoring and supervision from the tertiary level has been documented as one of the key barriers to implementation of IMCI among HCWs in Tanzania [23]. While poor mentorship and follow-up after DIMCI training may be partly explained by inadequate funding and transportation after funding has ceased, this may have contributed to a preference for standard IMCI training among some participants. This suggests a need for strengthening facility-based mentorship, supportive supervision and follow-up activities during and after DIMCI training. The successful implementation of DIMCI may require well-structured mentorship and follow-up activities. As such, the budget for supportive supervision may need to be increased for subsequent DIMCI implementation.
Our findings indicate that the problems encountered during DIMCI implementation included technological issues, such as inadequate facilities for personalized learning (e.g., TVs and computers) and the non-durability of DVDs. Technological challenges have been previously indicated as limiting the capacity of both HCWs and medical students to fully utilize the benefits of distance learning courses in Africa [24–26]. This suggests a need to ensure access to relevant technology among learners and the need for DIMCI materials to be available in multiple formats (e.g., DVDs and flash discs) to accommodate people who are unable to make use of the materials. The second challenge was personal issues, such as limited time for self-study due to competing work and family responsibilities and language barriers (with some recommending translation of contents into Kiswahili). Competing priorities among HCWs has been documented as a key challenge of implementing IMCI in Tanzania [23]. Nevertheless, language barriers suggest the need for translation of DIMCI materials into Swahili to ensure effective content delivery and absorption by HCWs within the country. The final challenge was design and coordination issues, such as low financial incentives and inadequate funds for mentorship, supervision and follow-up. These challenges may explain why there were mixed preferences for standard and distance IMCI, with some people expressing preference for distance IMCI because of its relatively lower cost and its ability to offer better work-study balance and critical thinking, while others preferred the standard IMCI because of the high possibility of knowledge retention. Most of these issues have been documented as common in other distance learning training models focusing on HCWs in Tanzania and other low-income settings [27–29]. Taken together, these findings indicate that, although DIMCI may be less expensive than standard IMCI, there is a need to address the challenges of DIMCI by considering the technological, personal and coordination barriers that HCWs in rural areas continue to face to maximize its success.
Despite the challenges observed, the findings indicate that DIMCI successfully facilitated the training of many healthcare workers, without jeopardizing patient management and at a low cost. DIMCI was linked to improved knowledge among HCWs, and improved competence in the management of under-five children. Such improvement was regarded as more likely to reduce deaths of newborns and mothers in future, with some participants affirming that the training had contributed to a reduction in newborn deaths. Other successes included improved confidence and capacity to identify and manage problems suffered by young children through the classification process using chartbooks, and improved use of the IMCI guideline for the management of childhood diseases. Similar findings have been reported in previous studies. For instance, Muhe [2] reported that DIMCI allowed many HCWs to be trained in parallel and that HCWs trained in DIMCI performed equally well as those trained in the standard IMCI. These findings need to be considered with caution as increased confidence and competence noted may deter HCWs at low-level facilities from providing timely referrals to some young infants with PSBI.

Sections

"[{\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR1\", \"CR2\", \"CR3\", \"CR6\", \"CR1\", \"CR5\"], \"section\": \"Introduction\", \"text\": \"Improving the capacity of healthcare workers (HCWs) to provide essential newborn care services has been widely recognized as a key entry point for reducing neonatal deaths. Cognizant of this, the World Health Organization (WHO), the United Nations Children\\u2019s Fund (UNICEF), and other partners have developed and supported the implementation of capacity building interventions for HCWs, including the integrated management of childhood illness (IMCI) strategy [1, 2]. Further, WHO has also developed a guideline on management of sick young infants with possible serious bacterial infection (PSBI) when a referral is not possible. The implementation of this guideline is documented as having the potential to contribute significantly to saving infant lives [3\\u20136]. Improving the skills of HCWs on both IMCI and PSBI is a critical strategy for reducing neonatal deaths in resource-constrained settings [1\\u20135]. This highlights the need for continued capacity building of HCWs in resource-limited settings to maximize their contribution towards preventing newborn deaths.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR7\", \"CR8\", \"CR1\", \"CR2\", \"CR9\"], \"section\": \"Introduction\", \"text\": \"IMCI training focuses on improving case management among HCWs, health system strengthening and promotion of good practices at both the family and community levels. Evidence indicates that the IMCI strategy has the potential to both improve the quality of care and prevent neonatal mortality [7, 8]. Despite its potential, the standard face-to-face training model (a residential 11-day training) has faced several concerns, including poor trainee coverage efficiency; absenteeism of trainees from health facilities for prolonged periods of time, which negatively impacts service provision; and a high cost of implementation, especially in resource-limited settings [1, 2, 9]. Consequently, the distance learning IMCI training model (DIMCI) (10\\u2009weeks with only 3-day face-to-face meetings among trainees and facilitators) is increasingly being promoted to address some of these challenges.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR6\", \"CR10\", \"CR15\", \"CR10\", \"CR10\", \"CR11\", \"CR12\", \"CR13\", \"CR6\"], \"section\": \"Introduction\", \"text\": \"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, treatment with appropriate antibiotics and follow-up [6]. Newborns in Tanzania are not exempted from developing signs of PSBI and requiring antibiotics. Evidence continues to indicate that infection-related neonatal deaths are a problem in Tanzania [10\\u201315]. While the country has witnessed a rapid decline in under-five mortality, there has been a much slower decline in deaths of newborns in the first month of life [10]. The rate of mortality among infants (children aged below 12\\u2009months) is 43 per 1000 live births [10], while the neonatal mortality rate (deaths during the first 28\\u2009days) is 25 per 1000 live births and contributes to more than 50% of infant mortality. The major causes of newborn mortality in Tanzania include birth asphyxia (31%), complications of prematurity (25%) and infections (25%) [11], placing Tanzania among the top 10 countries with the highest number (thousands) of newborn deaths in the world, and among the top five in sub-Saharan Africa [12]. A survey by Mangu [13] indicates that sepsis contributed to 29% of 26,630 newborn deaths documented between 2005 and 2015, with an increase in hospital-based neonatal mortality rates from 2.6 deaths per 1000 live births in 2006 to 10.4 in 2015. This indicates that training of HCWs \\u2013 to equip them with adequate knowledge and skills in identifying and timely managing sick newborns \\u2013 is among the key strategies for reducing infection-related newborn deaths [6]. Cognizant of this, UNICEF supported delivery of the DIMCI training during implementation of a pilot project for the management of young infants with PSBI in Mbeya region of Tanzania for the past 3 years.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR2\"], \"section\": \"Introduction\", \"text\": \"As the PSBI project is ending, it was important to conduct endline survey to examine how the DIMCI programme was implemented almost a decade after it started in Tanzania (See, [2]). This paper therefore examines participants\\u2019 accounts of the process used to implement the DIMCI training programme in Mbeya region. The paper draws from the data collected as part of an endline evaluation assessment that sought to assess and document the process used to implement the PSBI project, the outcomes achieved, and the lessons learned to inform recommendations for potential national scale-up based on the experiences of the three councils in Mbeya.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR16\"], \"section\": \"Design\", \"text\": \"A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of PSBI implementation in Mbeya Region of Tanzania. The endline evaluation took an implementation science approach, using mixed methods (qualitative and quantitative) for data collection. The use of qualitative descriptive approach for this inquiry was deemed appropriate to answer three key questions: (1) How was the DIMCI model implemented? (2) What were the achievements of the DIMCI model? and (3) what were the barriers encountered during implementation? A qualitative descriptive approach is appropriate for this inquiry as it aimed to develop an understanding and describe the implementation of DIMCI without testing an existing theory [16]. This approach offered an effective way of gaining a deep and rich understanding of the participants\\u2019 perceptions and experiences of DIMCI in the chosen context, as this may differ from other contexts in terms of culture, expectations and resources within health care settings. The qualitative data utilized for this paper were collected between June and August 2021.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR17\"], \"section\": \"Data management and analysis\", \"text\": \"As noted above, the research team did not use a theoretical framework; rather, participants\\u2019 descriptions of DIMCI were examined by considering training implementation in a specific context. This strategy allowed a contextualized exploration of issues related to implementation of DIMCI throughout data collection and analysis, without viewing it through an existing theoretical framework. Investigating DIMCI this way positioned our research within the constructivist paradigm, relying on participants\\u2019 descriptions to examine their perceptions and experiences of participation in the DIMCI in this specific context, rather than assuming it to be a positivist concept with a universally accepted framework of inquiry [17]. Future studies may consider a theory-driven inquiry in a similar context.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR3\", \"CR5\", \"CR3\", \"CR5\"], \"section\": \"Discussion\", \"text\": \"This paper describes the delivery of the DIMCI training programme during PSBI project implementation in the three district councils in Mbeya region. We utilized the data collected as part of an end-line evaluation that sought to assess and document the process used to implement the PSBI project, the outcomes achieved, and the lessons learned in the three councils to inform recommendations for potential national scale-up. Qualitative interviews were conducted with national, regional and district stakeholders, including trained beneficiaries and implementing partners, to generate an understanding of how distance IMCI was implemented. The study was constructed with the acknowledgement that prompt identification and treatment of sick young infants (aged 0 to 59\\u2009days) is key in reducing mortality and morbidity [3\\u20135]. While several interventions exist for the care of sick newborns in healthcare facilities, newborn morbidity and mortality remain challenges in Tanzania. As part of the response, UNICEF supported the Government of Tanzania to implement a three-year pilot project in the Mbeya region applying the new WHO PSBI guidelines in primary health facilities to provide guidance on the use of simplified antibiotic regimens. As part of PSBI implementation, HCWs were trained using the DIMCI training curriculum. The pilot project was constructed within the context of scientific evidence to the effect that implementation of the WHO guideline on the management of sick young infants with PSBI when a referral is not possible can contribute significantly to saving infant lives [3\\u20135]. Assessing the impact of the intervention, documenting the process of implementation of the distance learning IMCI programme and documenting the key lessons learned was therefore critical in offering recommendations that could inform scale-up both within and outside the country.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR1\", \"CR2\", \"CR9\", \"CR2\", \"CR18\"], \"section\": \"The origin of DIMCI in Tanzania\", \"text\": \"Examining its origin in Tanzania, the findings of the present study indicate that DIMCI originated from standard IMCI because of the need to enhance efficiency and deliver more cost-effective training courses. This need was fuelled by the desire to reduce training costs by reducing the number of days required for face-to-face training, maximizing the number of participants using limited resources, and reducing the prolonged absence of HCWs at facilities during class-based IMCI trainings (leading to service delays). Low coverage of IMCI, its high cost and the need for HCWs to be away from their workplace for a prolonged period, have been previously documented as common shortfalls of the standard face-to-face IMCI training [1, 2, 9]. Distance learning IMCI has been considered an innovative and low-cost alternative for addressing these gaps in the standard face-to-face IMCI training [2]. This implies that delivering IMCI through a distance learning model could be an important strategy for building the capacity of the healthcare workforce without requiring travel away from the workstation. These findings further indicate that DIMCI was also influenced by the global movements on PSBI, including global meetings for dissemination of recommendations for management of newborns. Consequently, local guidelines were reviewed, training modules and chartbooks were developed, and facilitators were trained with a pilot in the three districts. This may explain why the DIMCI programme implemented in Mbeya was adapted from WHO distance learning IMCI training curriculum [18]. This further implies that the DIMCI was implemented in Tanzania by adhering to global recommendations on implementing similar activities in low-resource countries. \"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR13\", \"CR19\", \"CR20\", \"CR21\"], \"section\": \"The delivery of the DIMCI: Structure, organization, contents, and beneficiaries\", \"text\": \"Our findings indicate that the delivery of DIMCI involved a face-to-face orientation session, several weeks of self-learning, group discussions involving healthcare workers within facilities and/or neighbouring facilities, and brief face-to-face examination and review sessions. The course contents included topics such as identification of danger signs, assessment and classification of severity using chartbooks, referral decisions and initial management before referrals (e.g., dosage), and the use of reporting tools and electronic system. Therefore, a focus on topics reflecting the major conditions contributing to newborn and under-five mortality in Tanzania was critical for maximizing the benefits of DIMCI. It is important to note that infections, delayed treatment, and delayed referrals have been previously documented as among the key contributors of newborn and under-five deaths in Tanzania, despite notable improvements [13, 19, 20]. Furthermore, research continues to indicate that frontline health workers have weaker capacity to provide quality and timely maternal and newborn care in Tanzania, with most needing additional training [21]. Therefore, a focus on nurses, clinical officers, assistant medical officers, and medical doctors is a critical aspect of DIMCI because they are the first individuals to handle sick newborns in primary healthcare settings. The selection of these frontline healthcare workers was conducted by a district IMCI focal person in coordination with the reproductive and child health coordinator and the Ministry of Health, partly because these people understand the capacity gaps within the healthcare system. Taken together, these findings imply that despite being delivered using a distance model, DIMCI was packed with topics that aimed to enhance the capacity of frontline healthcare workers to detect and manage newborns with PSBI in an attempt to increase their survival.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR2\", \"CR21\", \"CR23\", \"CR2\"], \"section\": \"The delivery of the DIMCI: Structure, organization, contents, and beneficiaries\", \"text\": \"The findings indicate that during the brief face-to-face orientation, DIMCI content was delivered via presentations and demonstrations by facilitators, group discussions and assignments, and homework. Self-directed learning was delivered via course modules, IMCI chart booklets, educative CDs/DVDs, photographic books, logbooks and exam sheets. Our findings largely reflect what has been documented in previous literature on implementation of DIMCI in Tanzania [2, 21\\u201323]. Muhe [2], for instance, documented DIMCI as consisting of three face-to-face encounters between IMCI trainees and IMCI facilitators and two self-study periods (3\\u20134\\u2009weeks and 8\\u20139\\u2009weeks) with self-directed learning for 10\\u201312\\u2009weeks for 4806 healthcare providers trained in 68 districts in Tanzania. This indicates that, in low resources settings, brief orientation and follow-up sessions are often needed on top of the self-directed learning, which may pose significant costs for the delivery of DIMCI.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR2\", \"CR23\"], \"section\": \"The comparison between DIMCI and the standard IMCI\", \"text\": \"A comparison of DIMCI and the standard face-to-face IMCI training model was carried out. Similar to the standard IMCI, DIMCI is expected to include mentorship and follow-up activities as part of continued support for learners. Follow-up visits are expected to be conducted 4\\u20136\\u2009weeks after training to assess clinical skills, reinforce clinical skills as well as provide supportive supervision, solve supply issues and ensure reporting [2]. However, our findings indicate some weakness in mentorship and follow-up of HCWs after the DIMCI training, with reliance on phone-based consultations with facilitators and peer group discussions. It is important to note that lack of mentoring and supervision from the tertiary level has been documented as one of the key barriers to implementation of IMCI among HCWs in Tanzania [23]. While poor mentorship and follow-up after DIMCI training may be partly explained by inadequate funding and transportation after funding has ceased, this may have contributed to a preference for standard IMCI training among some participants. This suggests a need for strengthening facility-based mentorship, supportive supervision and follow-up activities during and after DIMCI training. The successful implementation of DIMCI may require well-structured mentorship and follow-up activities. As such, the budget for supportive supervision may need to be increased for subsequent DIMCI implementation.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR24\", \"CR26\", \"CR23\", \"CR27\", \"CR29\"], \"section\": \"The challenges of DIMCI implementation\", \"text\": \"Our findings indicate that the problems encountered during DIMCI implementation included technological issues, such as inadequate facilities for personalized learning (e.g., TVs and computers) and the non-durability of DVDs. Technological challenges have been previously indicated as limiting the capacity of both HCWs and medical students to fully utilize the benefits of distance learning courses in Africa [24\\u201326]. This suggests a need to ensure access to relevant technology among learners and the need for DIMCI materials to be available in multiple formats (e.g., DVDs and flash discs) to accommodate people who are unable to make use of the materials. The second challenge was personal issues, such as limited time for self-study due to competing work and family responsibilities and language barriers (with some recommending translation of contents into Kiswahili). Competing priorities among HCWs has been documented as a key challenge of implementing IMCI in Tanzania [23]. Nevertheless, language barriers suggest the need for translation of DIMCI materials into Swahili to ensure effective content delivery and absorption by HCWs within the country. The final challenge was design and coordination issues, such as low financial incentives and inadequate funds for mentorship, supervision and follow-up. These challenges may explain why there were mixed preferences for standard and distance IMCI, with some people expressing preference for distance IMCI because of its relatively lower cost and its ability to offer better work-study balance and critical thinking, while others preferred the standard IMCI because of the high possibility of knowledge retention. Most of these issues have been documented as common in other distance learning training models focusing on HCWs in Tanzania and other low-income settings [27\\u201329]. Taken together, these findings indicate that, although DIMCI may be less expensive than standard IMCI, there is a need to address the challenges of DIMCI by considering the technological, personal and coordination barriers that HCWs in rural areas continue to face to maximize its success.\"}, {\"pmc\": \"PMC9854197\", \"pmid\": \"36658537\", \"reference_ids\": [\"CR2\"], \"section\": \"The success of DIMCI implementation\", \"text\": \"Despite the challenges observed, the findings indicate that DIMCI successfully facilitated the training of many healthcare workers, without jeopardizing patient management and at a low cost. DIMCI was linked to improved knowledge among HCWs, and improved competence in the management of under-five children. Such improvement was regarded as more likely to reduce deaths of newborns and mothers in future, with some participants affirming that the training had contributed to a reduction in newborn deaths. Other successes included improved confidence and capacity to identify and manage problems suffered by young children through the classification process using chartbooks, and improved use of the IMCI guideline for the management of childhood diseases. Similar findings have been reported in previous studies. For instance, Muhe [2] reported that DIMCI allowed many HCWs to be trained in parallel and that HCWs trained in DIMCI performed equally well as those trained in the standard IMCI. These findings need to be considered with caution as increased confidence and competence noted may deter HCWs at low-level facilities from providing timely referrals to some young infants with PSBI.\"}]"

Metadata

"{\"issue-copyright-statement\": \"\\u00a9 The Author(s) 2023\"}"