|Emergency and Disaster Training Exercises - Training the Trainers in Cold Chain Operation. TR. EX. 33 (World Health Organisation, 4 p.)|
* Based on the documentation Logistics and cold chain: a workshop for EPI trainers, available in English and French from WHO Regional Offices or from EPI, World Health Organization, 1211 Geneva 27, Switzerland.
WHO Chronicle, 34: 182-185 (1980)
The cold chain which maintains vaccine potency from manufacturer to users in remote tropical areas is the lifeline of the WHO Expanded Programme on Immunization (EPI), now in operation in some 100 developing countries. But the cold chain is not simply a succession of refrigerated containers and stores, cold boxes and vaccine carriers; it is above all the people, transporters, programme managers, storekeepers and vaccinators who handle the vaccine at different stages of its journey. Failures in the cold chain, including mechanical breakdowns, are often due to lack of proper training. A one-week course for middle-level cold chain personnel has been devised by EPI in WHO headquarters and tested in the field. Its aim is to enable participants to improve their cold chains by providing suitable training for the cold chain workers under their supervision.
Workshops on logistics and cold chain for EPI trainers have now been held many times in countries including Benin, Fiji, India and Thailand with a total of more than 100 participants.
The course is intended for middle-level workers concerned in the cold chain such as district supervisors, health centre medical officers, maternal and child health nurses, repair technicians and supervising vaccinators. It lasts five and 1 half days and its aim is to strengthen and modify what participants already know about the cold chain, and to enable them to learn what to teach other people and how to teach it. When they return to their jobs, they will be expected to train health staff at the local level in vaccine handling, refrigerator care, and other ways of improving the efficiency of vaccine collection and supply systems.
At the end of the course participants should be able:
· to identify the priority training needs in their cold chain;
· to decide what training is needed;
· to select and develop suitable training materials and methods;
· to construct an outline cold chain course at local level; and
· to prepare an action plan to get the course started.
A feature of the workshop is the absence of formal lectures. Participants learn through practical exercises, group activities and case studies. They are divided into four groups: (a) vaccinators, nurses, midwives and their supervisors, (b) health centre chiefs and their supervisors, (c) repair technicians and their supervisors, and (d) storekeepers and their supervisors. The results of group work are presented and discussed in plenary sessions.
It is assumed that all participants have experienced and found answers to some cold chain problems and that someone in the group will already have met, in real life, almost any problem that may come up for discussion. The core of the course consists in confronting the participants with a series of imaginary problems which they attempt to solve from their experience. The answers proposed by the different groups are pooled, and the group responsibility is then to decide how the lessons of that problem can best be taught - by producing posters, writing lecture notes, making instruction manuals, etc. Finally, the groups meet to prepare the training materials that have been agreed upon.
Pre-test and post-test
On the first morning of the course, participants are given a pre-test to discover how much they already know. On the last morning of the week, they are given the post-test. The tests are identical and consist of some 40 multiple-choice questions. The differences in pre-test and post-test scores can be used to evaluate how much a participant has learned, and also the strengths and weaknesses of the course. Scores typically change from 35% to 65%. Here are some of the test questions:
· The only way to ensure that a vaccine keeps its potency is by:
(a) regular temperature testing;
(b) organized and precise handling throughout its history;
(c) destruction of all vaccines beyond expiry date;
(d) constant checking for visible deterioration.
· If vaccine has lost its potency you can revitalize it by cooling it to 4 °C.
True or false?
· You can assume that a refrigerator already installed in a health centre is safe to use for vaccines.
True or false?
· Your car breaks down while you are transporting vaccine, and you cannot repair it quickly. Can you suggest ways of solving this problem?
· List one advantage and one disadvantage for each of the following training media or methods when used for the cold chain:
The cold chain game
This is a simulation game in which the participants take on the roles of cold chain workers, storekeepers, supervisors, etc., and learn the complex nature of these tasks. The game consists in organizing and running a series of vaccine stores. The pieces in the game are vials of vaccine. Players have to request vaccine, store it properly, keep records, and despatch it correctly. The objective of each player is to keep his store in good order - not overfull but with enough vaccine to keep pace with the demand. There are no winners or losers; the objective of the game is learning how to run a cold chain.
The game is played twice, on the first and last afternoons of the course, and is designed to imitate a cold chain in a way that is simple at first and becomes increasingly complex. If a participant finds the game useful for his future teaching activities, he can be provided with instructions on how to organize it and get the necessary materials copied and manufactured locally.
The case studies
The course includes 11 studies of typical problems found at three different levels in the cold chain - village level, district level and state level. These case studies are distributed among the four working groups. A typical case study will present a problem that has occurred frequently in a cold chain, and the groups are asked to solve it in three steps by answering the following three questions: What should be done immediately to meet the difficulty? What should be done to prevent it from recurring? What training is needed to enable the people concerned to prevent the problem recurring?
One case study for group I (vaccinators, nurses and midwives) is the following:
Ahmed the vaccinator goes by bicycle to his prearranged vaccinating site. It takes him 20 minutes. He organizes his vaccinating session and starts work, vaccinating and recording. At 12 noon he notices that the ice around his remaining vaccine has almost melted.
The sample answer sheet lists a total of 21 things in answer to one or other of the above three questions. Most participants in the course find even more answers than this during the discussions. Here is another case study, for group 3 (storekeepers and repair technicians):
Scene: Your programme manager has said that you must expand the immunization programme 10 five more districts. UNICEF has said that It cannot supply any more equipment this year for your cold chain. You have discovered that you can buy cold boxes and carrying flasks In the local market. You need five cold boxes and fifteen flasks.
Questions: What should you check before you purchase these items?
How can you test if the equipment is good enough to be used In the cold chain?
The sample answers to this one fill one and a half pages.
The group presentations
During the second half of each morning, the different groups present the answers found the previous evening to the case studies, so that the other groups can make comments and offer criticism. In the afternoon, the groups are re-formed and participants prepare training materials that will be useful for them when they return to their jobs. These materials are typed out overnight and distributed the following day to all groups. Thus each participant receives four sets of training materials, those prepared by his own group and those prepared by each of the other three groups.
Advice for organizers of local courses
On the morning of the last day but one of the course, participants work individually through the guide Provide cold chain training, which tells how to prepare a cold chain course at local level. They then write an individual action plan for the cold chain training they mean to organize over the subsequent 12 months. The plan is then presented to the other participants. The office running the workshop uses these individual action plans for the long-term follow-up and evaluation of results.
The guide, which forms part of the material given to all participants, contains advice of a most practical kind on how to organize a short training session of anything from half a day to three days in length, and proffers the following basic principles of effective training:
As far as possible:
· Allow the participants to choose what they learn. This will increase their motivation.
· Encourage the participants to be active in the course - they will learn more.
· Show the participants regularly what progress they are making - this will increase their learning speed.
· Remember, the less you teach, the more they learn.
The authors of the guide are also very clear as to what training can and cannot do. They introduce the guide with the following words:
People respond to the problem of training in a number of ways.
Some people say, there is nothing to it, just tell the person what you want him to do.
Others consider it overwhelming - how do I make sure that all the people working under me know what they should be doing?.
Still others look upon it as the answer to all their programme problems.
Training is none of these things - it is neither very simple nor very complex; nor can it solve all the problems in a health programme (or any other programme for that matter).
What it can do, when it is used effectively, is to reduce those problems which occur when a person does not know how to do his job. A person may not do his job for a number of other reasons (he may dislike his boss, have other duties he considers more important, not have enough time to do his well, etc.). These problems will not be solved by training.
and conclude it with the warning:
Do not believe that your workshop will change nothing.
Do not believe it will change everything.
The following working documents are given to participants:
· Cold chain technical guide (66 pp.). This is a source document containing the technical information needed to answer the case studies.
· Cold chain pre-test and Cold chain post-test. The two documents are identical and contain some 44 questions.
· Evening case studies (18 pp.).
· The cold chain game (9 pp. and 14 pp. annexes). This is a manual for people who, having played the cold chain game, may wish to organize it for others.
· Cold chain pre-test and post-test sample answers (8 pp.).
· Case study sample answers (17 pp.).
· Provide cold chain training (11 pp.). Advice for organizers of courses.
· Cold chain workshop evaluation. This contains a questionnaire for participants and a method for analysing answers.
· Reproductions of sample posters and handouts actually used in EPI programmes.
What participants take home
Before the closing session there is an evaluation in which participants are invited to criticize and make suggestions on improving the logistics and cold chain course. The first three times the workshop was held, the participants evaluations were 86%, 85% and 89% satisfaction.
At the end of the week, each participant will be in possession of the following:
· Three or four sections of a cold chain course, one prepared by each of the working groups (depending on how many groups are formed);
· instructions on how to make and play the cold chain game;
· instructions and suggestions on how to organize his own cold chain training sessions;
· an individual action plan for cold chain training in his area for 12 months after the end of the workshop;
· examples of cold chain training materials that have been produced in other countries.
How to run a logistics and cold chain workshop
The logistics and cold chain course is designed for between 10 and 20 participants with four to eight course managers. In order to run the course for the first time, it is necessary to have at least two supervising course managers who already have experience in a course. In this way, two supervising course managers from an earlier course can train a further two to six managers for future workshops. At present, a good number of course managers have been trained in different parts of the world.
In general, the workshop is organized as a presidential course for five and a half days. The participants appear to gain from this approach since much of the work has to be done privately in the evenings. They also seem to appreciate the opportunities thus provided to discuss their common cold chain problems.
No long-term evaluations of this course are yet available, since the first workshop was run in April 1979. The proof of the success of this course is not how much people learned but how much they taught others in the subsequent 12 months.
The following cold chain material is also available from EPI, World Health Organization, 1211 Geneva 27, Switzerland.
The cold chain. Module 3. Part 2 of EPI programme managers course. 35 pp. (English and French). A one-and-a-half day briefing for programme managers on planning a cold chain.
A guide for estimating storage capacities for EPI vaccines, 2 pp. (English and French).
The cold chain. A district level case study. 9 pp. (English and, from mid-1980, French).
Looking after your vaccine. A set of 20 colour slides with accompanying text of 8 pp. (English and French, available from mid-1980).
Looking after your cold chain equipment. A set of 20 colour slides with accompanying text of 10 pp. (English and French, available from mid-1980).
This refrigerator protects lives. A poster for the door of a vaccine refrigerator (Arabic, English, French, and Spanish).
Free in small quantities; US$ 250 per 1000 in bulk.
Look after your vaccines every day
A set of three comic strip style posters (English and French).
Free in small quantities; US$ 300 per 1000 in bulk.
The cold chain: or how vaccines should be handled. A 30-minute 16 mm colour film with sound track (English and French). Available on loan, or can be purchased for US$ 200 per copy.
Stop! Do you need to open it? A sticker for a refrigerator door (English, French and Spanish). Free in small quantities; US$ 100 per 1000 in bulk.
Vaccine. Rush. A sticker for vaccine packages giving a warning about proper handling (Arabic, English, French, German and Spanish). Free in small quantities; US$ 120 per 1000 in bulk.