'Off the shelf and into action'--the ICM pilot project on training of midwives in HIV care: detailed planning and stakeholder involvement are key elements in this important ICM initiative, which is led by Nester T Moyo, ICM Programme Manager.

Plans for an ICM project which would make an effective and appropriate contribution to the global fight against HIV and AIDS have been in development for some time. The selection of this health issue as a focus for ICM action is based on the knowledge of the rising numbers of women affected by HIV and the devastating impact on the women themselves, their babies and families, and their role as caregivers in personal, community and professional capacities, including those who work as midwives. Among the Millennium Development Goals, those relating to maternal and child health are the primary focus for midwives; however, particularly in the least developed countries, addressing the goals of sickness, poverty and gender equality is crucial to progress towards them all.

A cascade of training

On March 12-17, 2006, the first pilot workshop of the training programme 'Promotion of HIV and AIDS Prevention, Treatment, Care and Support' was held in Port Alfred, Eastern Cape, South Africa. This workshop is the first part of the pilot study of training for midwives and other health care workers of the ICM and its collaborating partners Medical Knowledge Institute and University of Fort Hare. The pilot study, funded by the Dutch Red Cross, aims at testing the effectiveness of the project design in scaling up training on prevention, treatment, care and support of women with HIV and AIDS and their newborns. The 14 health workers attending came from eight of the nine provinces of South Africa.

The project is designed to create a critical mass of trainers of trainers in each country. The trained 'master trainers' from the first workshop will go on to train midwives and other health care providers to contribute to the combatting of HIV and AIDS in their country. It is a three-tier process.

The curriculum was approved by the World Health Organization and is geared towards skills acquisition. The pilot study will test whether the project methodology is effective in producing the desired outcomes. The results of the study are of critical importance for the modification of the project before implementation on a large scale.

Critical stakeholder and professional support was created from the training workshop. Four directors of programmes (one national and three provincial), six provincial managers and four co-ordinators were trained. Their involvement will potentially make implementation of the project easier. The workshop design, content and mode of delivery were effective as shown by participants demonstrating via evaluation that the objectives of the workshops had been met. Participants also made presentations on their action plans which were in line with the project design and confirmed the design was understood by participants.

The selection criteria used for identifying participants brought together a diverse group with different levels of information on the various aspects of HIV and AIDS prevention, treatment, care and support. This enriched the group as the participants from different backgrounds complemented each other. The varied experiences of the trainers will potentially strengthen the implementation of the second phase. One possible drawback of me selection was that, apart from one pharmacist participant, the group was made up entirely of midwives.

Design and content of the workshop

Over the five days, the participants concentrated on the following areas:

* HIV and AIDS epidemiology, natural history and progression

* Counselling and testing

* Treatment, care and support

* Continuing education for midwives and other health care providers

* Strategic planning 

* Networking and resource mobilisation

* Communication and action plans.

However, as well as providing information and advice in these areas during the workshop, it was extremely important to consider other aspects of the project in order to minimise the risk of failure owing to participants losing motivation or feeling unsupported in the later stages of the planned work.

The 'training of trainers' (TOT) model has specific characteristics. Its success depends on:

* professional and political support

* availability of resources, both human and financial

* supportive supervision

* the appropriate type of participants being involved.

Professional and political support

For a ToT workshop it is important to create a supportive coalition of people who support both the idea and the follow-up process, including those who are directly implementing the activity, the people to be trained, the trainers and anyone else who has a stake in the process. Other stakeholders may be people in policy-making positions both professionally and politically, administrators, managers, representatives from NGOs, beneficiaries and other professional groups--as well as those who may be inclined to block progress.

Availability of resources

For a ToT programme to work there must be money and people available. In midwifery one of the biggest problems is rapid turnover of staff due to increased mobility and migration. It is important to ensure that enough numbers are involved from the start so that even if some move, there are still enough people to continue the activities. The financial demands, too, cannot be ignored. As the roll-out progresses, there is need to invest finances to support the programme

Supportive supervision

Trainers feel lonely and isolated after training if there is no supportive supervision. Frequent and regular contact helps to sustain motivation, share ideas, offer new information, and support technically and emotionally.

Types of participants involved

Participants must be people who are able to 'de-role'--who are willing to function at the same level as the people they are training but with additional insights and skills--and are keen to see others succeed. Their keenness to see others succeed will make them more willing to transfer skills and knowledge. They must be creative and innovative in identifying ways in which others can learn. They appreciate other people's contributions and they bring the best out of other people. This aspect makes other people more willing to be around them and to learn from them. Trainers of trainers make others feel they can do it too.

Trainers of trainers do not suffer from intellectual morbidity brought about by fear of challenge and opposition. They see challenges and obstacles as opportunities for learning and growth. In a difficult situation, they try everything possible, make modifications and then try again.

To teach/train is to learn and lead. Trainers of trainers enjoy learning and helping others learn what they have learnt. In that way they become leaders in learning.

People who have to train as trainers should be people with the right perception of their own self-worth so that they are able to see success and failure in an objective manner. They should take criticisms from other people, including prospective trainees, in the light of the programme rather than as a reflection of their own value as an individual.

No midwife or health care provider should have the attitude that it does not concern her/him. It concerns everyone. The health of the community depends on our contributions. If we withhold our contributions, then we too suffer the consequences of an unwell community.

These types of characteristics were shared and discussed with the workshop participants. The participants were encouraged to look for these characteristics in identifying their prospective participants for the next stage of training.

Mode of delivery in the workshop

A core element of the delivery was that the 'messages' had to be conveyed in a sustainable fashion so that they would not be lost as the chain of training of trainers continued. There was therefore a strong focus on teaching/learning strategies that used physical actions, humour, emotions and wordplay of all sorts. These were aimed to provide stimulation and elicit responsiveness among the participants and make the workshop a striking and highly memorable experience. In this way, it is hoped they will be not only skilled but motivated to take the process forward.

Among the opening moves, for example, it was suggested that participants 'leave their shoes on the doorstep'. The feeling of being not properly dressed but also knowing that everyone is in the same situation helped the participants to realise that as a trainer of trainers one needs to be humble or at least be on the same level with the trainees.

The session on counselling skills was conducted through role play, illustrating the concepts and the salient features of each reason for counselling. This was another effective way of having people with different levels of information and knowledge facilitating the diffusion of knowledge and skill among participants. The participants critiqued each other's presentation and gave helpful suggestions.

Practice presentations were captured on tape to allow the participants to comment about themselves as if they were commenting on somebody else's presentation. Some of the issues highlighted were: how to use a Powerpoint presentation effectively; use of language to show respect for the audience; time management when working under pressure; group control techniques, distracting mannerisms, dress code, body language, poise and confidence. Among other mnemonic strategies, trainers should remember to use the 'three Is': Intelligence; Integrity; and 'I can do it!'

During discussion, there was considerable use made of sayings, proverbs and quotations, some of which are highlighted around this report.

Three further quotations are taken direct from the feedback of the workshop participants:

"... very relevant and presented in an enthusiastic manner." "The blocks that came up were made into stepping stones and we continued to achieve our objectives."

"Believe me I am getting educated in this place. I will leave this place a different person!"

The above summary is based upon a full report by Nester T Moyo; the photos were taken by Dr Harold Robles of MKI.