Francesco Marinucci DETT 607 Assignment 2: Learning Design July 10, 2011 Word Count: 1893

Integrated HIV Laboratory Medicine Course for Medical Laboratory Technology Students in Kenya: Learning Design

Course overview The purpose of this paper is to present a learning design for the course titled Integrated HIV Laboratory Medicine Course for Medical Laboratory Technology Students in Kenya. The overall goal of this course is to support five Kenyan universities in producing graduates trained in all aspects of HIV clinical laboratory medicine for an effective disease diagnosis and management. During the course students are stimulated to apply the theoretical aspects covered in different classes to the clinical settings through learning material focused on HIV and AIDS diagnostics. Upon completion of this course learners will be more knowledgeable regarding HIV diagnostics and become acquainted with the Standard Operating Procedures necessary for producing quality and reliable results. Because of the growing new technologies available in many Kenyan medical laboratories, there is urgent need to standardize the diagnostic protocols. In the area of CD4+ T-cells enumeration the technology transfer is more massive and an intervention focused on quality testing is urgently needed.

Therefore the module related to CD4+ T-cells enumeration techniques is developed with the aim of applying similar instructional design to the other sections of the course. In Table 1 below are reported the 10 modules for this course. Table 1
Topic MODULE 1 Epidemiology and Biology of HIV MODULE 2 Screening tests Description - Introduction on HIV epidemiology with emphasis on African context - Immunology of HIV infection and HIV transmission - Testing strategies and testing algorithms - Description and selection of screening tests - Rapid assays - Description of confirmatory tests - Overview on different types of confirmatory tests - Different types of NAAT assays - Manual CD4 count - General principles of flow cytometry - Overview on antiretroviral therapy - Common ARVs side effects - Laboratory drug monitoring (clinical chemistry, hematology) - Development of drug resistance - Drug resistance testing (Genot. Vs. Phenot.) - The Quality System - Standard Operating Procedures - Medical laboratory accreditation - Good Laboratory Practice - Waste management Country specific policies and guidelines for medical laboratory services

MODULE 3 Confirmatory tests MODULE 4 Nucleic Acid Amplification Test (NAAT) MODULE 5 CD4+T cells enumeration techniques MODULE 6 Testing for Drug Toxicities

MODULE 7 Testing for Drug Resistance MODULE 8 Laboratory Quality Management

MODULE 9 Laboratory Safety MODULE 10 Kenya National Strategy for HIV Control

Module 5 overview Accurate enumeration of CD4+ T-cells allows for different clinical decisions, such as monitoring HIV disease progression, determining level of immune progression, prediction of susceptibility to opportunistic infections, and assessment of immune system restoration for patients receiving antiretroviral therapy (ART). Too often the Standard Operating Procedure (SOP) for peripheral blood CD4+ T-cell counts, which is the single most important diagnostic parameter in the management of patients infected with Human

Immunodeficiency Virus (HIV) in Kenya, is limited to the description of the testing stage of the Total Testing Procedure (TTP) as per manufacturers recommendation. This course addresses the gaps related to both pre-analytical and post-analytical stages of SOP that are crucial to provide reliable quality results. This course will guide students through all the steps of the TTP for this parameter to be included in the SOP. At the end of the course students will master the SOP stages and will be able to apply them to the different CD4 techniques currently available in medical laboratories in Kenya. Measurable learning objectives This module will prepare the learner to be able to do the following:
1. Describe the different uses and related quality issues of CD4 cell enumeration in managing HIV positive patients 2. Describe how CD4 cells absolute count and CD4 cells percentage are calculated and their better use in the clinical management of adults and children

3. Explain the different steps in each of the three phases of the TTP in regard to CD4 cell enumeration
4. Define the principles of flow cytometry, mechanics of fluidics and fluorescence 5. List the different CD4 platforms based on sample throughput available at different laboratory levels in Kenya 6. Evaluate the quality of flow cytometry dot plots 7. Distinguish between preventive and corrective maintenance and how to track it 8. Explain the importance of running daily controls for CD4 cell enumeration 9. Describe the three components of External Quality Assurance programs 10. Develop a Standard Operating Procedure for CD4 testing based on specific laboratory settings

Theoretical background

This course aims at developing skills by building on prior knowledge gained by the students. For this reason some values of constructivist theory are taken in consideration in the instructional design. In particular all five principles proposed by Lebow (1993) are followed and the tendency to control the learning situation and the desire to promote personal autonomy carefully balanced. Due to the nature of the course and the peculiar audience, the course is oriented at applying the prior knowledge to real situation by offering students the opportunity of modeling problem-solving processes and take control of the learning process. Both aspects are two important tasks BSc graduates are expected to carry out in their real working environment. The former because they have the knowledge (compared to the average laboratory staff in Kenya), skills and attitude to propose solutions and drive continuous improvement in the laboratory. The latter exposes them to the importance of self-study as pillar of their continuous professional development that is crucial in biomedical sciences. The instructional process comprises all four phases for effective learning as presented by Merril (2002), with special emphasis on application of skills and integration of these skills into real world. Based on Kellers (1987) model of motivational design the strategies for motivating the learners are listed below.

Attention: To attract students and hold their attention the course will offer the unique opportunity to: a. b. c. d. Apply their knowledge to real-world settings through interactive learning Experience web-based instruction as innovative way of learning Be trained by an US-based institution Perfect their skills by watching videos played in real medical laboratories

Relevance: The content of the course is relevant to the students because it will help them to: a. b. c. d. Apply the theoretical aspects covered in different courses to the clinical settings Be aware of the different roles played by medical laboratory services in fighting HIV epidemic in their country Understand the importance of their commitment in ensuring scientific knowledge, quality of testing and ethical behavior in this endeavor Be able to become leaders in their sector by applying scientific reasoning and problemsolving approach

Confidence: To develop learners confidence the course will: a. b. c. d. Be accessible only to students with higher grades Provide learning guidance and communication with instructor and other students Provide options in learning paths to increase learner control Encourage students to interact with the instructor for timely feedback

Satisfaction: The course will be satisfactory by giving the learners: a. b. c. d. . The chance of turning their knowledge into skills through problem-solving approach The satisfaction of resolving issues in real-world settings The professional and personal satisfaction of providing high-quality service A more competitive profile for the current job market in Kenya

In addition, because of demonstration of skills and of their application and integration to real settings, participants will gain expertise applicable at their first job. This trait will help them in making scientific-sounded decisions and, potentially, to have leadership roles, with the overall goal of making this course relevant and hence increase participants motivation (Keller, 1997). For this purpose the design of this course is based on Merrils (2007) taskcentered instructional strategy, and emphasis is given to demonstration rather than

discovery or exploration, by integrating prior knowledge and skills during the learning process. The whole task is the Total Testing Procedure of CD4 cell enumeration (CD4 TTP) that is accomplished by demonstrating and repeating the same sub-tasks per each topic, every time enriched with additional elements to increase sub-tasks complexity. In Figure 1 below are presented the different sub-tasks of this instructional strategy.

Figure 1 Subject matter content Each module starts with combined audio and visual presentation to introduce the task. To avoid redundancy effect, the audio part will describe the most challenging subtasks so to maximize the split effect as described by Kalyuka, Chandler and Sweller (2000). The sub-tasks are identified by IHV-UMSOM laboratory team and based on their extensive experience in face-to-face and on-site laboratory trainings (more than 1,500

laboratory workers) in Sub-Saharan Africa. Following the task presentation students are asked to provide a written description of the task presented. As next step learners are provided with specific readings, such as guidelines and chapters of textbooks. The audio and visual presentation is showed again and participants are asked to provide a more detailed description of the task based on the content of the readings. This step is repeated by providing scientific papers on the topics. At next stage a visual presentation only is showed with some sub-tasks omitted. The learners are asked to provide a list of the omitted sub-tasks and an explanation of their importance in the whole task. Interaction To start-up socialization among students, an ice-breaker activity will be launched during the pre-week course. At the beginning of each topic students will be engaged by introducing the whole task with a video played in real-setting. This will promote a projection of the learners to the stage and keep them interacting with the content. The approach would be let me see how the whole task is supposed to be performed in a real setting, and compare the quality of the same whole task in two environments very similar. By comparing the two processes students are stimulated to search the differences and analyze the reasons for such variations. To complement the video message, other media will be used to guide students in the analysis and engage them in interaction with the subject-matter. Two modalities will be used to motivate students in interacting with peers. The first one comprises a description by all students on how the whole task is performed in the laboratory where they are attached. All students have to post it and answer at least to another students post. In addition, two-person group discussion focused on specific sub-tasks will be facilitated. The main means provided for student-

student interaction will be the conference area through asynchronous communication. This is mainly due to the scarce availability of personal internet access by students, but also to allow student to practice critical thinking. Student-instructor interaction will be ensured through immediate feedback via email, while text messages through mobile phones will be used to keep students engaged. The latter means can sound unusual in web-based instruction, but in Kenya mobile phones are accessible to all students population all the time and text messaging keeps the dialogue with the instructor open. For this purpose Swahili version of the software SMSFrontline will be used by coinstructor based in Kenya. Assessment strategies In the figure 2 below for each objective are described the Action, Condition, and Criterion as per Reiser and Dick (1996) description.
LESSON 1 ACTION Write a short essay CONDITION With assigned reference materials CRITERION Grading rubric (see Annex 1) on completeness of the list and explanation of the different uses Without any reference 12.5% per correct answer materials Without any reference 5% per correct answer materials With reference Accuracy of description materials provided by instructor With any reference material With reference materials provided by instructor With users manual as reference material With any reference materials With reference materials provided by instructor 20% per correct answer

2 3 4

7 8 9

Answer 8 multiple choice quizzestime sensitive Given a set of 20 items, assign them to the right phase of TTP After reading the reference materials participants identify and write technical features of two flow cytometers Given specific scenarios (5) select the appropriate CD4 platform based on laboratory level and patients load Given four dot plots decide if to accept or reject them and explain the reasons Select one CD4 platform and draft maintenance log book Answer 4 case-scenario questions Write an essay on the importance of the three components of External Quality Assurance program for CD4 testing

25% per correct answer based on correct answer and accuracy of the explanation Correspondence between users manual and log book 25% per correct answer Grading rubric

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Develop SOP for two CD4 platforms and write the differences between the two SOPs

With reference materials provided by instructor

Grading rubric

Figure 2 Feedback Regular feedback will be provided in 1-2 days at the end of each assignment/test to highlight both strengths and weaknesses in learner performance. At regular intervals a text message in Swahili to comment on the status of their learning process will be sent on the mobile phone of each learner. In the conference area of web-tycho Instructors office will be always open as option for asking questions at any time. Course outline
MODULE Introduction to CD4 cells enumeration Sample collection Sample preparation Sample testing Results analisys, recording, and reporting Quality CONTACT HOUR 3 hrs TIME-FRAME 2 days

3 hrs 2 hrs 4 hrs 2 hrs

2 days 1 day 2 days 2 day

6 hrs 20 hrs

5 days 14 days

Conclusion The learning design presented above for the course titled Integrated HIV Laboratory Medicine Course for Medical Laboratory Technology Students in Kenya has the overall goal of stimulating critical thinking by exposing students to real-cases through problem-solving and group discussions. The most critical steps related to the quality of

the Total Testing Procedure for CD4 count are presented, analyzed and reiterated by using different media format and communication technologies. To Instructor Designers knowledge this is the first attempt to provide web-based pre-service training to Medical Laboratory Technology students in Kenya. The learning design approach described does not intend to replace hands-on trainings necessary to develop the technical skills, but rather to complement the practical component of pre-service trainings by promoting quality thinking in future laboratory workforce in Kenya.

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ANNEX 1
GRADING RUBRIC for ASSIGNMENT #1 Description of different uses and related quality issues of CD4 cell enumeration in managing HIV positive patients GRADE SCALE A (90%-100) 13.5 - 15 points B (80-89%) 12 - <13.5 points C (70-79%) 10.5- <12 points F (< 70%) Below 10.5 points

Addressed but does not completely fulfill requirements Note: no points will be awarded in a category if the category is not addressed at one of the levels described below. Description 2.7 - 3 points 2.4 - 2.6 points 0 - 2.3 points of different Clearly identifies: Clearly identifies: Identifies most, but not uses of CD4 - different uses of CD4 count - different uses of CD4 all, of the different uses cell (e.g., monitoring HIV count (e.g., monitoring of CD4 count required enumeration progression, opportunistic HIV progression, to meet requirements in managing infections, immune system opportunistic infections, OR HIV positive restoration following ART) immune system Lists all elements but patients - CD4 threshold for starting restoration following lacks sufficient clarity to ARV therapy in Kenya ART) set the clinical context - types of equipment for CD4 - CD4 threshold for for CD4 count detection in use in Kenya starting ARV therapy in AND Kenya Relates CD4 count to WHO - types of CD4 detection staging and clinical symptoms equipment Exceeds requirements

Meets requirements

Description of quality issues related to CD4 count

Description of proposed

2.7 - 3 points Clearly identifies: - the type/s of issues (e.g., skill level, lab management system, human error, intra-lab or intra-hospital error, etc.) - the degree of severity of error - to which extent the error(s) identified affects CD4 count result AND Shows knowledge and rigorous application of Good Laboratory Practices above average in identifying and classifying errors 2.7 - 3 points Clearly identifies:

2.4 - 2.6 points Clearly identifies: - the type/s of issues (e.g., skill level, lab management system, human error, intra-lab or intra-hospital error, etc.) - the degree of severity of error - to which extent the error(s) identified affects CD4 count result

0 - 2.3 points Addresses most, but not all, of the elements required to meet requirements AND/OR Does not present a convincing description/classification of errors and their impact on CD4 count analysis

2.4 - 2.6 points Clearly identifies:

0 - 2.3 points Addresses most, but not

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solution(s) to address quality issues in CD4 count

Justification for proposed solution(s) to address quality issues in CD4 count

Writing and presentation

- what the possible cause(s) of error is - action to be taken after the error is identified - how the solution may be implemented - the expected results on performance AND Shows knowledge and rigorous application of Good Laboratory Practices above average in problem solving approach 2.7 - 3 points Presents reliable evidence to support the proposed solution, such as: - technical background - clinical implications Presents a convincing argument concerning how the evidence supports the solution AND Appropriate use of published research (peer-reviewed journals) as source of evidence 2.7 - 3 points Presents material in a logical manner, including an introduction, main body, and conclusion Writing has few, if any, spelling, grammatical, or punctuation problems All sources are referenced and presented in correct APA format Word limit is not exceeded (within 5%) AND Shows creativity in presentation by selecting effective techniques for efficiently communicating the required information (e.g., may include appropriately formatted text, graphics, diagrams, tables, and/or illustrations)

- what the possible cause(s) of error is - action to be taken after the error is identified - how the solution may be implemented - the expected results on performance

all, of the elements required to meet requirements AND/OR Does not present a convincing problem solving approach, its cause/s, and why the action(s) proposed is the best option

2.4 - 2.6 points Presents reliable evidence to support the proposed solution, such as: - technical background - clinical implications Presents a convincing argument concerning how the evidence supports the solution

0 - 2.3 points Presents evidence, but it is not sufficient to support the proposed solution AND/OR It is not sufficiently clear how the evidence is supposed to support the proposed solution

2.4 - 2.6 points Presents material in a logical manner, including an introduction, main body, and conclusion Writing has few, if any, spelling, grammatical, or punctuation problems All sources are referenced and presented in correct APA format Word limit is not exceeded (within 5%)

0 - 2.3 points Includes required components, but writing is lacking in logical flow AND/OR Contains several spelling, grammatical, punctuation problems AND/OR Sources are not properly referenced

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References

Kalyuga, S., Chandler, P., & Sweller, J. (2000). Incorporating learner experience into the design of multimedia instruction. Journal of Educational Psychology, 92(1), 126136. Keller, J. M. (1997a). Motivational design and multimedia: Beyond the novelty effect. Strategic Human Resource Development Review, 1(1), 188-203. Keller, J. M. (1987b). Strategies for stimulating the motivation to learn. Performance & Instruction, 26(8), 1-7. Lebow, D. (1993). Constructivist values for instructional systems design. Educational Technology Research and Development, 41(3), 4-16. Merril, D. (2002). First principles of instruction. Educational Technology Research and Development, 50(3), 43-59. Merrill, M. D. (2007). A task-centered instructional strategy. Journal of Research on Technology in Education, 40(1), 5-22 Reiser, R. A., & W. Dick (1996). Instructional Planning: A guide for teachers. Boston, Allyn and Bacon.

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