Francesco Marinucci DETT 607 Assignment 1: Context Analysis June 18, 2011 Word Count: 1858

Integrated HIV Laboratory Medicine Course for Medical Laboratory Technology Students in Kenya: A Context Analysis

Introduction Center for Diseases and Infection Control and Kenya National AIDS Commission gave an American university the mandate of providing advanced clinical education on HIV to different cadres of health workers in Kenya. The training project described below addresses training needs of laboratory workers in Kenya and it is built on the extensive experience the Global Laboratory Program (GLP) of the Institute of Human Virology of the University of Maryland School of Medicine gained in supporting medical laboratory services in 7 countries in Sub-Saharan Africa and 2 in the Caribbean Region with more than 1500 laboratory professionals trained in the past seven years. The overall goal of the project is to support five Kenyas Universities in providing web-based instruction for integrated and comprehensive high quality training on HIV laboratory medicine. The rationale behind this training approach is to renovate traditional learning to reflect the growing new technologies available in many Kenyan medical laboratories. A first obstacle to educating laboratorians in becoming skilled on HIV laboratory medicine is the

low number of well-trained educators available at country level. A second major hindrance is the pedagogical approach of abundant lecture-based laboratory trainings where the teaching methodology only transfers information without stimulating an active learning process. These determinants are well described by Rowe, de Savigny, Lanata, and Victora (2005) that identified the efficiency of trainings as one key area related to human capacity to be addressed. Organizational context In Kenya the universities offering graduate course on Medical Laboratory Technology are: Nairobi University, Kenyatta University, Jomo Kenyatta University, Moi University, and Maseno University. Their common mission is to produce graduates who are trained in all aspects of clinical laboratory medicine for effective disease diagnosis and management. Even if the laboratory curricula currently in use by these Universities incorporate Ministry of Health Laboratory Guidelines there is lack of integrated training on HIV laboratory medicine. Problem analysis Due to the size of HIV epidemic in country huge investments in fighting this disease took place in the past ten years from different international donors. From laboratory perspective these efforts resulted in an unprecedented technology transfer. GLP carried out a baseline needs assessment by reviewing laboratory curricula at the universities, visiting the training laboratories, and by interviewing both students and faculty. Based on Morrison, Ross & Kemps definition (2007) of needs, the major gap identified between the existing conditions and what is expected is that the training medical laboratory technology graduates receive at university level does not reflect the

new medical laboratory settings in country. Among the six identifiable categories of needs proposed by Morrison et al., both Comparative and Felt Needs were recognized. For the former category the target audience was compared to the status of the medical laboratories in terms of quality using as measurable indicator the score obtained with WHO-AFRO Accreditation checklist. The Felt needs were highlighted through questionnaires and face-to-face interviews of graduate students at all five universities. The majority of interviewees pointed out that newly graduated medical laboratory technologists gain a global picture of the roles of medical laboratory in the context of HIV epidemic only during their first working experience. This lack of information causes a learning-by-doing process where knowledge is applied to practice very often with limited orientation and supervision. The major consequence is the underperformance of laboratory workers that results in poor quality of medical laboratory services. A second consequence is the disparity of both intellectual and technical skills among laboratory professionals with same degree and studies. Therefore, GLP identified as best option a learning solution in the form of a comprehensive course covering different facets of HIV in line with the updated National Laboratory Guidelines. The knowledge gained by medical laboratory technology students on HIV is vast but it is limited to specific subjects without having a global picture. It is important that they know how to apply the knowledge on this subject to the clinical settings where they are expected to work. Therefore there is need of putting the different pieces of knowledge on HIV together and translate theory into practice in the context of Kenya medical laboratories settings. By adopting this course, graduates from all five universities receive standardized training on HIV laboratory medicine according to the

national standards for laboratory professionals as required by the Kenya Medical Laboratory Technician and Technologist Board. Audience/target population analysis At the end of their studies, graduate students are expected to know how to apply the knowledge to real-world situation and how to turn it into practical skills. This is true only if during their studies they are engaged by their instructors in using knowledge, by modeling problem-solving processes, resolving case-studies, self-questioning (Lebow, 1994), and, if required, by having hands-on trainings. Last-year medical laboratory technology students in Kenya are the target audience because of the information about HIV they already received in subjects as Public Health, Epidemiology, Microbiology, and Immunology, but from a theoretical academic perspective only. The successful attendance to these courses (grade B or above), together with Information Technology courses, constitutes the minimum requirements for the audience of this web-based course. Because of their broad scientific basis to build on and the active exploration of new knowledge, last-year students are stimulated to build connections through a constructive learning approach (Wang & Gearhart, 2006). As per Wang & Gearhart description all five universities ensure Institutional Readiness by offering strong technic al infrastructure and adequate support services for smooth operation (p. 16). Faculty Readiness and Instructional Material Readiness (Wang & Gearhart) are initially provided by GLP and the instruction designer. Proposed solution course overview By adopting a web-based course the barriers showed above can be easily overcome. The pedagogical approach followed for this course encompasses different

activities and methodologies with the main goal of transforming the learning experience from a passive one-time event to a continuously active process. In Fig. 1 below are illustrated how the different activities and methodologies influence the six areas of the learning process. Fig. 1 The six areas of the learning process
100
Creating

75 50 25 0 self-learning study written essays case studies group work plan discussion development

Evaluating Analysing Applying Understanding Remembering

Course goals and objectives The major goal of this course is to apply the theoretical aspects covered in different courses to the clinical settings through learning material focused on HIV and AIDS diagnostics. Upon completion of this course learners are more knowledgeable regarding HIV epidemic and able to: 1. Understand and describe the different roles played by medical laboratory services in HIV care and treatment programs 2. Contextualize these roles in the Kenya National Strategy for HIV Control 3. Apply a quality-oriented approach to medical laboratory operations and procedures 4. Develop a work plan aimed at increasing technical and management skills of peers

5. Understand the value of self-learning as continuous active process for professional development Delivery media analysis Students enrolled in this course receive an orientation where challenges of time management in web-based instruction and course management system features are widely presented. The course is delivered via WebTycho, while the media used are paper-based material, electronic libraries and multimedia. The former medium is mainly used for transferring knowledge through self-learning, while the latter is helpful for presenting case-studies and promoting problem-solving activities. Electronic libraries support students during their assignments. The web is not only used to deliver written content but also for videos showing real-scenarios from medical laboratories. Learner-learner and learner-instructor interaction is offered only through asynchronous communication technologies. The course comprises 10 modules covering different topics (Table 1) for an effective laboratory support of HIV care and treatment programs in Kenya. After an introduction of both participants and course content, the students have access to the first module. At this stage the communication between trainer and student is limited while the learner-content interaction is high. This portion is dependent on self-regulation and motivation, driving students to develop critical autonomy, self-efficacy, and individual organizational skills. At the end of each time-sensitive module, students must complete an assessment test named Competence Assessment Test (CAT) and send the results back to the instructor for scoring. Following the CAT, participants are asked to discuss case studies and to solve real-world problems, first as individuals and then as group. This

collaborative learning activity helps students in developing high-level reasoning and interpersonal skills, but there are also the benefits of considering multiple perspectives (Lebow, 1994). In addition, based on Wang & Gearhart (2006) perspective, the competence developed through cooperative learning is easily transferred to learners individual work. The three activities (self-learning, case studies and problem solving) will reflect real-world settings as much as possible by providing authentic learning tasks. This approach follows the first five principles of problem-centered instruction as described by Merril (2002). In addition to the knowledge assessment test at the end of each module, students are required to prepare a short essay (~600 words) every three modules. These 3 essays are intended to keep the dialogue between instructor and trainee active and to evaluate students capacity of applying the knowledge acquired to real-world settings (i.e. their future workplace). For this purpose the students will be asked to choose among three topics to reflect on the current practice of HIV laboratory medicine in Kenya. The essays are important for supporting intrinsic motivation, meaningful learning, and self-esteem. Each student shares the essays with other participants to stimulate peer discussion and course-content enrichment. Both CAT and personal essays, together with the interaction of instructor with students, will be used for formative assessment (Wang & Gearhart). Table 1
Topic MODULE 1 Epidemiology and Biology of HIV - Introduction on HIV epidemiology with emphasis on African context - Immunology of HIV infection and HIV transmission MODULE 2 Screening tests - Testing strategies and testing algorithms Description

- Description and selection of screening tests - Rapid assays MODULE 3 Confirmatory tests - Description of confirmatory tests - Overview on different types of confirmatory tests MODULE 4 Nucleic Acid Amplification Test (NAAT) MODULE 5 CD4+T cells enumeration techniques - Manual CD4 count - General principles of flow cytometry MODULE 6 Testing for Drug Toxicities - Overview on antiretroviral therapy - Common ARVs side effects - Laboratory drug monitoring (clinical chemistry, hematology) MODULE 7 Testing for Drug Resistance - Development of drug resistance - Drug resistance testing (Genot. Vs. Phenot.) MODULE 8 Laboratory Quality Management - The Quality System - Standard Operating Procedures - Medical laboratory accreditation MODULE 9 Laboratory Safety - Good Laboratory Practice - Waste management MODULE 10 Kenya National Strategy for HIV Control Country specific policies and guidelines for medical laboratory services - Different types of NAAT assays

Conclusion The function of medical laboratories in Kenya is indispensible for quality outcomes of HIV care and treatment programs in the context of the National Strategy for HIV Control. To maximize new technology potential available in Kenyan medical laboratories there is need of pre-service course on HIV laboratory medicine aimed at

applying the knowledge to real settings and at turning it into practical skills. The best option identified for this purpose is a web-based course targeting last-year medical laboratory technology students who meet the minimum requirements (completion with B grade minimum of Public Health, Epidemiology, Microbiology, Immunology, and IT courses). By adopting this course, graduates from all five Kenyan universities receive standardized training on HIV laboratory medicine and they are put in the condition of being able to apply their knowledge at their first working experience.

References

Lebow, D. (1994). 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.

Morrison, G.R., Ross, S, & Kemp, J.E. (2007). Ch.2: Identifying the need for instruction. In Designing Effective Instruction, (5th, pp. 28-51). New York: John Wiley & Sons.

Rowe, A.K., de Savigny, D., Lanata, C.F., Victora, C.G. (2005). How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet, 366, 1026-35. doi:10.1016/S0140-6736(05)67028-6

Wang. H. & Gearhart, D.L. (2006). Designing and developing web-based instruction. Upper Saddle, Pearson Education.