Training of Trainers for Trichiasis Surgeons

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1 Training of Trainers for Trichiasis Surgeons

2 Background To achieve the GET 2020 objectives of eliminating blinding trachoma in all endemic countries, concerted efforts will be needed to address the backlog of cases of trichiasis; the blinding stage of trachoma. Currently there is an estimated 7 million people with trichiasis throughout the endemic world awaiting counseling and intervention whether it be surgery or improved epilation techniques. In scaling up trichiasis programs, two aspects will be critical: increasing the quality of surgery and TT management; and, increasing the number of patients the health system identifies and provides one form of management or another. In the Global Scientific Meeting for Trachomatous Trichiasis, held in Moshi, Tanzania in January 2012, one of the key factors cited for increasing quality of surgical outcomes was improved training for trichiasis surgeons. One element of training was to increase the trainers knowledge and application of adult learning principles to the training context. Most often trainers of TT surgeons are identified by their technical knowledge and surgical skills but with little attention paid to how good of a trainer they are. This is an area that this manual attempts to address. The objectives of this manual are thus to introduce TT surgeon trainers to the principles and primary governing concepts underlying adult learning and to frame this knowledge within the context of a national trachoma programme. The manual works with participants in the design of training interventions and the design of individual training sessions. Time is provided to put this knowledge into practice by asking participants to choose a session from the newly revised WHO manual Trichiasis Surgery for Trachoma and to design and present a lesson to the other participants. This manual is an accompaniment to both the above referenced WHO manual and the newly developed manual for Head- start Training. Head Start is the newly developed analog training manikin that allows surgeons in training to practice on a life- like head and eye prior to graduating to live patients. Information on Head Start is found in a separate manual.

3 Contents Background... 2 Schedule & Outline of Activities... 4 Training sessions... 5 Session 1: Introductions... 5 Session 2: Expectations/Agenda and Objectives... 6 Session 3: Norms... 7 Session 4: Pre- test... 8 Pre- test... 9 Session 5: Adult learning principles Session 6: Key Concepts of Training Session 7: Planning a Training Session 8: Designing a Training Session Session 9: Additional Training Topics for TT Surgeons Session 10: Review/Questions for Day Session 11: Review of the WHO Trichiasis Surgery for Trachoma Manual (Yellow Manual) as a Training Manual Session 12: Planning for the Training Practicum Session 13: Training Practicum... 16

4 Schedule & Outline of Activities Day 1 Time Session Activity :00 1 Introductions 10:00-11:00 2 Expectations - Agenda and Objectives 11:00-11:15 3 Norms 11:15-11:30 Coffee 11:30-12:15 4 Pre-test 12:15-13:00 5 Principles of adult Learning 13:00-14:00 Lunch 14:00-14:45 6 Key concepts of Training 15:00-15:45 7 Planning a Training 15:45-16:00 Coffee 16:00-16:30 8 Designing a Training Session 16:30-17:30 9 Additional Training Topics for TT Surgeons Day 2 Time Sessi Activity on 9:00-9:30 10 Review/questions related to the previous day of work 10:00-11:15 11 Review of WHO TT Manual as a Training Manual 11:15-11:30 Coffee 11:30-13:00 12 Planning for the Training Practicum 13:00-14:00 Lunch 14:00-15:30 13 Training Practicum 15:30-15:45 Coffee 15: Training Practicum 17:00-17:30 14 Closing

5 Training sessions Session 1: Introductions Session Summary: This introductory session is critical as it sets the tone for the training of trainers workshop. As this entire workshop is designed to be participative and embrace adult learning principles, this session should communicate to the participants this approach. As with any training activity there should an objective to it. Using an interactive approach requiring the participants to get up, move about reinforces the concepts of accountability, participatory, and safety; concepts that will be discussed later in the day. There are many such ice breaking activities and the one below is only a suggestion. Objectives: 1) To demonstrate this is a participatory workshop and expects full participation from each learner; 2) To demonstrate that the participants are responsible for their learning and the facilitator is there to facilitate the learning but not impose it. 3) To allow the participants and facilitator to interact and to get to know one another creating a sense of community and safety within the learning environment; Duration: 60 minutes Materials: flip chart and markers 1) Ask the participants to form a circle that also includes the facilitator; 2) The facilitator tells the participants that one by one person will start by standing up, announcing their name, where they are from and something about themselves (e.g., dream vacation spot or favorite sport) 3) The next person must say the name of the first person, his sport, and then state his/her own name. 4) The third person must say the names and sport from each of the people before and then add his/her name. 5) This is continued all the way around to the last person who needs to remember everyone s names and sport. 6) Following this activity, the facilitator asks the participants to comment on the value of such an activity writing their responses on flip chart. 7) Some responses to bring up are: allow participants to become acquainted; to develop a sense of community; help relax people; set a climate of participation and instant involvement of all; to demonstrate that the facilitator is part of the group and not a

6 leader or lecturer; to provide the facilitator with a sense of the group and individuals that will help as the workshop proceeds. Session 2: Expectations/Agenda and Objectives Session Summary: Participants attend workshops with a variety of expectations as to the nature of the workshop and as to what they will gain from their participation. These expectations may be different from the intentions of the organizers and if not discussed at the beginning of the workshop may cause confusion, dissatisfaction and in the end hinder the learning process. This and the following session provide an opportunity to identify those expectations and reconcile them if possible with the workshop objectives and if not possible address the reasons why the expectation(s) cannot be met. Objective: 1) To determine the expectations the participants have in attending the workshop and their learning needs in terms of training (and trachoma). 2) To establish a pattern of group work for the workshop. 3) To discuss this activity and its role in workshop facilitation Duration: Materials: 60 min Flip chart paper Markers 1) Ask each participant to write down 3 expectations they have for attending the workshop. By expectations we mean what the participant hopes to learn or achieve by attending the workshop. 2) Allow the participants 5-10 minutes to develop their list after which form groups of 2-3 people. 3) Ask these groups to share their expectations with each other and then develop a group list of 3 expectations arriving to a consensus of what the most important points are. 4) Depending on the number of participants, this could be replicated one more time forming larger groups with each group coming to consensus on the most critical areas. 5) Bring the participants together and invite one group to present their expectations writing down their responses on flip chart paper; 6) Ask the other groups if they had any different expectations to add to the list, writing these down on the flip chart. 7) At this point present the objectives and agenda;

7 8) Ask the participants what are the advantages and disadvantages of this way of working together (responses may include: group work; developing common learning goals; sharing ideas and experiences, learning more about the other participants; while disadvantages might include: too much time; too difficult to manage; reporting takes too much time and/or repetitious). 9) If disadvantages are brought up discuss how those disadvantages might be mitigated (just start with a larger group and not individuals; 10) Since the group will become trainers, ask participants how they might manage participants expectations that fall outside the planned agenda (change the agenda; see where in the agenda at least a part of the expectation might be met; meet the expectation by adding time to the agenda, etc.) Note that the GTMP manual also includes information about expectations of the trainees involved in the surveys. Ask the participants to read through the short section and provide any comment. 11) Review the agenda and discuss the participants own expectations modelling how this activity might be conducted. Session 3: Norms Session Summary: This session is to establish behaviours that the participants agree will be necessary to have a successful and productive workshop. Objective: 1) To set the ground rules for behaviours during the workshop; Duration: 15 minutes Materials: flip chart and markers 1) Ask the participants what norms are (behaviors/rules that all agree on); 2) Brainstorm with the participants what they feel are the necessary norms for this to be a successful workshop (answers may include: not speaking at the same time, respect for others opinions, no side conversations; turn off cell phones, no smoking, etc.) 3) Write the responses on the flip chart; 4) Ensure that all participants are in agreement; 5) Post the flip chart on a wall of the training room to be referred to if needed.

8 Session 4: Pre-test Session Summary:. This session further establishes the participatory nature of the workshop and defines trachoma as the context of the rest of the training. Questions may be added or changed as the facilitator s discretion. Objective: 1) To introduce trachoma and the various facets of control to the participants; 2) To develop an understanding among the facilitators of the knowledge level off the participants; Duration: 45 minutes Materials: flip chart and markers Handouts: Pre-test (test questions may be prepared on flip chart paper beforehand) 1) Pass out the pre-test to each individual. If the test is prepared on flip chart paper ask each participant to take out a piece of paper and pen and post the test on the easel. 2) Ask each participant to answer the questions to the best of their ability; 3) After 5 minutes, divide the participants into groups of three; 4) Instruct each group to take the test as a group sharing their individual answers to the test; 5) After 10 minutes, bring the participants back together. 6) For each test question, ask for their responses and write the answers on flip chart paper. 7) After all the different responses for one question have been written down, discuss with the participants the answers indicating which are correct elaborating as necessary; 8) Proceed in this manner with the rest of the questions; 9) Let the participants know there will be a presentation on trachoma and if they have any questions they can be addressed then.

9 Pre-test 1) What are 3 socio-economic risk factors for trachoma? 2) Name the 4 components of the SAFE strategy. 3) How does WHO define trichiasis? 4) Who is at most risk of trichiasis? 5) Name 2 ways that trichiasis can be managed? 6) What should you do if someone refuses to have surgery?

10 Session 5: Adult learning principles Session Summary: This session is designed to allow the participants to reflect on the dynamics of adult learning and how the principles of adult education can be applied during their task of training trachoma survey workers. This session will be the first step to introduce the concept of experiential learning or learning by doing. Often public health training programs rely on doctors to conduct the training who in turn model their experience in medical school by lecturing and assuming that the participants are a blank slate with no prior experience that might contribute to the success of the workshop. Objective: 1) To introduce or review key principles of adult learning theory through self-reflection and through available knowledge from social scientists; 2) To analyze what constitutes an effective learning experience. Duration: 45 minutes Materials: 1) flip chart and markers; 2) sheet of flip chart paper with the title Adults learn best when: a) they are able to apply their own past experience to what they are presently learning; b) they have the opportunity to share with their peers; c) they are treated with respect and dignity; d) what is being learned is relevant to their lives; e) they will have the immediate opportunity to apply what is being learned; f) practice is provided as part of the learning experience; 4) a flip chart that has 20% hear; 40% hear and see; 80% do; 5) a powerpoint slide with the Experiential Learning Cycle or a flip chart paper with the cycle. 1) Ask the participants to individually reflect on a recent learning experience they participated in focusing on a) what was learned; b) what the context was in which the learning took place; c) who assisted in the learning; and, d) what elements contributed to the learning. This can be anything and not necessarily related to health. 2) After 5 minutes, divide the participants into groups of two to three. 3) Ask each group to discuss among themselves each individual s experience and as a group to identify 4-5 factors that contributed to their learning. These factors can complete the sentence Adults learn best when-. Allow minutes. 4) In the large group, ask the small group to share the factors they identified, writing them down on the flip chart entitled Adults learn best when: and discussing their applicability. 5) Share with the group the prepared flip chart listing 6 factors; 6) Indicate where the results of the participants work overlap with the ideas presented on this paper;

11 7) After the discussion of the last factor, post the flip chart 20% hear, etc. and discuss. 8) Finally, ask the participants to recall the way they learned in secondary school/university and ask them to contrast it with the way adults learn. 9) Present the Experiential Learning Cycle relating it to the discussion held during this session. Indicate that there may be variation on how one individual goes through the cycle. Experiential Learning Cycle Session 6: Key Concepts of Training Session Summary: This session reviews and introduces a number of key concepts for the participants to discuss for the training of trachoma survey members. The key terms are: Safety (the learning environment is one that he/she can be challenged to learn and perform new skills needed for the trachoma survey without any sense of embarrassment) Objectives (we need to train towards specific objectives based on the needs of the survey and the capacity of the people to carry out the survey) Respect: (a survey trainee feels that his/her ideas will be listened to and considered and is a peer of all others (including the facilitator) in the workshop Accountability (refers to all being responsible for their roles (facilitation/learning) in order to properly carry out the survey Proof of learning (this refers to how trainers can establish that the learners are in command of the knowledge or skills on how to carry out the trachoma survey).

12 Objective: To provide the opportunity to review and to introduce some key concepts within adult education to discuss their application to the participant s role as a trainer of TT surgeons Duration: 45 minutes Materials: flip chart paper with the above concepts written on them; index cards each with one of the above concepts written on them depending on number of participants there may need to be 2-3 cards with the same concept written on it 1) Divide the participants into groups of three. 2) Distribute 2-3 cards to each group ensuring each group receives three different concepts; 3) Ask each group to discuss the concepts they have received and arrive at a definition of that concept within the context of training; 4) Have each group present one of the concepts. Write the key point on flip chart paper. 5) After each concept, ask if another group that addressed that concept has anything different or something to add; until all 6 have been covered writing the key point on flip chart paper; 6) Ask the participants how they will ensure that this key concept can be applied during the training of TT surgeons. Session 7: Planning a Training Session Summary: This session breaks down the steps in planning a trachoma survey training workshop. The key questions are Why? (What is the situation), What for? (The objectives), How? (Steps, activities, materials), Who? (Who is to be trained/who is training); When? (The time frame);; Where? site for training. There is no one right answer and the facilitator should expect some variation. This session will lead into the practicum in which participants will choose a topic to train their fellow participants in using these steps in their planning. Objective: Duration: To analyze the various steps in need of consideration when planning training 45 minutes Materials: 1 set of cards with each step written on them for each group of 3-4; masking tape or some other adhesive

13 1) After introducing the session, break the participants into groups of 3-4; 2) Distribute one set of cards to each group; 3) Ask each group to order the cards in what they think is the most logical order for planning a training; 4) Ask the participants to tape the cards on the wall in the order they decided upon. 5) Ask each group about their decisions on the order stating that there is no one right response; Session 8: Designing a Training Session Session Summary: This session is the lead in to the practicum. It is to breakdown the considerations that need to go into planning a training session such as the training objectives, the learning outcomes, the materials and handouts as well as the training procedure. Objective: To provide the participants with the tools to plan for a training session. Duration: 30 minutes Materials: Flip chart and markers; power point with a sample lesson 1) Ask the participants what should be included in a training lesson plan; 2) Write the responses on the flip chart, seeking clarification where necessary; 3) Present the power point slide as an example asking participants for questions, comments or requests for clarifications. Session 9: Additional Training Topics for TT Surgeons Session Summary: Though the key aspect of training TT surgeons will be on the surgery itself, there are other competencies that a TT surgeon and thus his or her trainer needs to know as well. This session is to identify those competencies and discuss the details of each. Objective: To develop a list of additional training topics of competencies TT surgeons should have command of other than surgery and to flesh these topics out Duration: 45 minutes hour

14 Materials: Flipchart and markers 1) Ask the participants what additional topics TT surgeons should have command of to be effective in their job. Write the responses on the flip chart. 2) Ask the participants to prioritize the topics identifying the 3-5 most important topics. 3) Discuss with participants what the key elements of the 3-5 prioritized topics are. (These topics can be used for their practicum). Session 10: Review/Questions for Day 1 Session Summary: This session is to provide an opportunity to review the work from Day 1 and to answer any questions participants may have, clarify any aspects that remain unclear and to briefly review the adult learning particularly in the context of training trichiasis surgeons. Objective: To review the work from Day 1 to ensure all participants are clear on the various learning points Duration: 30 minutes Materials: none 1) Ask the participants if they have any questions; 2) If there are any questions, ask the other participants to share their understanding of what has been asked with the facilitator sharing his or her own thoughts;; 3) Ask the participants what they felt was the most important aspect of Day 1 in relation to their role as a trainer;

15 Session 11: Review of the WHO Trichiasis Surgery for Trachoma Manual (Yellow Manual) as a Training Manual Session Summary: The WHO manual for TT surgery has recently been updated and should be seen as the definitive guide for perform surgery whether through the Bilamellar Tarsal Rotation Procedure or Trabut. The manual however is more of an instructional guide rather than a training manual. This session asks the participants to review the WHO Manual in light of the previous day s discussions of adult learning and to share ideas of how to improve this document as a training manual. Participants will be asked to read through the first section of the manual first and then join a group to share their ideas and suggestions. The following session builds on this as groups of participants develop a training session as part of their training practicum. Objective: To review the WHO Trichiasis Surgery for Trachoma manual within the context of adult learning Duration: 75 minutes Materials: copies of the WHO Trichiasis Surgery for Trachoma manual for each participant 1) Distribute a copy of the manual to each participant; 2) Ask the participants to review pages 1-13 of the manual in relationship to all of the discussions of Day 1 thinking of ways that this manual could conform more closely to adult learning principles and the design of training sessions; After minutes, ask the participants to form groups of 3 and within ach group discuss their individual conclusions as to the WHO manual and ways to improve it; Bring the participants back to plenary and ask the different groups to share their ideas. Session 12: Planning for the Training Practicum Session Summary: The participants will be asked to present a lesson either from the additional topics identified during the session Additional Training topics for TT Surgeons or from the WHO Trichiasis Surgery for Trachoma (yellow manual) using the format discussed in the session Designing a Training Session. The participants will work in groups of three to share their knowledge and experience in the design and in the practicum. These groups should be preselected by the facilitator basing the selection on such criteria as language, understanding of the

16 material, experience in training, etc. The facilitator may assign each group a specific topic or let the groups decide for themselves. Objectives: To allow the participants to practice designing a training session. Duration: 90 minutes Materials: Computer per group, flip chart and markers, Yellow Manual Handouts: None 1) Announce the groups that will be working together and the topic if the facilitator feels it better to assign each group one. 2) Ask the groups to design a 20 minutes training session that they will present that afternoon. The lesson may address one of the topics discussed in Session: Additional Training Topics for TT Surgeons or one of the non-surgical topics in the Yellow Manual. 3) Inform the groups that if their lesson is longer than 20 minutes, they are allowed to describe what else they would do. 4) Also inform the groups if there is a material they would like to use but is not immediately available, they can describe that as well. 5) Advise the groups that they have 90 minutes to do so. Session 13: Training Practicum Session Summary: This session is to provide each group an opportunity to present their lesson with the rest of the participants serving as the trainees. Each group should be given 20 minutes to present. Following each session the other participants can offer suggestions as to how to improve. To avoid debate or arguments, each comment should be prefaced with the statement: I would suggest you consider doing (suggestion). The response by the presenting group should be no more than Thank you. Objectives: 1) To provide an opportunity for the participants to practice training: 2) To provide the participants with an opportunity to critically analyze a training session. Duration: 2.25 hours Materials: Each training group will decide for themselves Handouts: Each training group will decide for themselves

17 Ask a group to go first; 1) Following the session, ask the trainers how they felt the session went; 2) Next ask the participants what suggestions they may have to improve the session. Please note the instructions in the Session Summary. 3) At the end of the session, the facilitator should sum up the practicum by referring to the various elements that embodied adult learning.

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