Improving Interprofessional Collaboration: Building Confidence Using A Novel HIV Curriculum For Healthcare Workers Across Sub-Saharan Africa
University Of Global Health Equity, Kigali, Rwanda
University Of California San Francisco, USA
Addis Ababa University, School Of Medicine, Ethiopia
Ukwanda Centre For Rural Health, Stellenbosch University, South Africa
School Of Public Health, Kwame Nkrumah University Of Science And Technology, Ghana
University Of Nairobi, Kenya
Faculty Of Medicine And Health Sciences, University Of Zimbabwe
Kamuzu University Of Health Sciences, Malawi
University Of Botswana Faculty Of Health Sciences, Botswana
Kilimanjaro Christian Medical University College, Tanzania
School Of Nursing And Public Health, University Of Kwazulu-Natal, South Africa
School Of Health Sciences, University Of Kwazulu-Natal, South Africa
University Of Zambia School Of Nursing Sciences, Zambia
Department Of Virology, College Of Medicine, University Of Ibadan, Nigeria
Faculty of Health Sciences, Makerere University
ACHEST, Kampala, Uganda
†Corresponding author Michael Reid, University of California, San Francisco, Institute for Global Health Sciences, 550 16th Street, Third Floor, San Francisco, CA 94158, USA, Telephone: Fax: +(1) 415-476-6953, E-mail: Michael.reid@ucsf.eduAbstract
The 21st century presents significant global health challenges that necessitate an integrated health workforce capable of delivering person-centered and integrated healthcare services. Interprofessional collaboration (IPC) plays a vital role in achieving integration and training an IPC-capable workforce in Sub-Saharan Africa (SSA) has become imperative. This study aimed to assess changes in IPC confidence among learners participating in a team-based, case-based HIV training program across diverse settings in SSA. Additionally, it sought to examine the impact of different course formats (in-person, synchronous virtual, or blended learning) on IPC confidence. Data from 20 institutions across 18 SSA countries were collected between May 1, 2021, and December 31, 2021. Logistic regression analysis was conducted to estimate associations between variables of interest and the gain in IPC confidence. The analysis included 3,842 learners; nurses comprised 37.9% (n=1,172) and physicians 26.7% (n=825). The majority of learners (67.2%, n=2,072) were pre-service learners, while 13.0% (n=401) had graduated within the past year. Factors significantly associated with increased IPC confidence included female gender, physician cadre, completion of graduate training over 12 months ago, and participation in virtual or in-person synchronous workshops (p<0.05). The insights gained from this analysis can inform future curriculum development to strengthen interprofessional healthcare delivery across SSA.
Article notes
Competing Interest Statement
One of the authors, Judy Khanyola, is an editor at PLOS Global Public Health.
Clinical Trial
NA
Funding Statement
None
Introduction
Despite substantial research indicating that interprofessional education (IPE) enables effective collaborative practice leading to improved health outcomes and stronger health systems,[1-6] there is a paucity of data describing strategies to enhance interprofessional education and collaborative practice (IPECP) in Sub-Saharan Africa (SSA).[7] In this paper, we evaluate the impact of a multi-country HIV IPE training program to improve learner confidence in interprofessional collaboration (IPC). The program, which included both in-service and pre-service learners from 18 SSA countries, assessed the impact of three different formats for interprofessional learning on learner IPC confidence: in-person workshops, synchronous virtual workshops, and online workshops that blended asynchronous and synchronous components. By examining changes in IPC confidence after completion of the training and determining if course format had any impact on IPC confidence change, this analysis sought to inform curriculum development to strengthen interprofessional collaborative practice across SSA.
Background
By 2030, it is estimated that SSA will face a shortage of 6 million healthcare workers, creating an urgent need to train a health workforce capable of responding to the numerous health challenges experienced by the region.[8] To address this need, diverse team-based interprofessional education (IPE) programs can play a critical role, preparing health professions trainees to deliver high-quality care in Africa, particularly in areas with a high burden of HIV.[9-12] One such educational initiative is the STRengthening InterProfessional Education for HIV (STRIPE HIV) program,[9] which aims to optimize team-based HIV care through the delivery of a curriculum consisting of case-based lessons targeting pre-service learners and early career in-service health professionals in high HIV burden countries across SSA. The program leverages a continent-wide network of health professions training institutions and affiliated health educators that are part of the African Forum for Research and Education in Health(‘AFREHealth’).[13]
Methods
Study Design and Subjects
The study was conducted using data from the STRIPE HIV program, which aimed to optimize team-based HIV care through a curriculum consisting of 17 case-based modules targeted at pre-service learners and early career in-service health professionals in high HIV-burden countries across Sub-Saharan Africa. The program included learners from 20 institutions in 18 countries. The curriculum was delivered in three formats: in-person workshops, virtual workshops (conducted synchronously on Zoom), or a blended online course (which included an online asynchronous component followed by a virtual synchronous component). The choice of learning format, which of the 17 case-based modules are taught, and the mix of learners engaged in the training was determined by local collaborating institutions and has been described previously. [9, 10]
IPC Confidence Assessment
All learners who completed both the pre-test and post-test assessment for any of the 17 modules between May 1, 2021, and December 31, 2021, were included in the study, regardless of professional cadre (physician, nurse or midwife, pharmacist, laboratorian, etc.), stage of professional development (pre-service, less than 12 months of graduation, or greater than 12 months post-graduation) or geographic setting. These assessments captured learners self-reported confidence in IPC on a 4-point Likert scale prior to the course and following course completion, with one confidence assessment question for each module completed. The primary objective of this analysis was to examine changes in IPC confidence after completion of the curriculum and to determine if course format had any impact on IPC confidence change.
Statistical Analysis
Descriptive statistics were used to summarize the demographic characteristics of learners and mean changes in IPC confidence for each demographic and each module. Individual learners were classified as having a gain in IPC confidence if their post-course self-reported IPC confidence score was higher than their pre-course self-reported IPC confidence score. We estimated associations between variables of interest and gain in IPC confidence using logistic regression; the dependent variable was the outcome of whether the learner reported an increase in IPC confidence or not, and the independent variables of interest included course format, gender, profession, time since graduation, and number of completed course modules. A chi-squared test (two-sided) was used to compare study groups. Statistical significance was set at p<0.05. All analyses were conducted using Stata version 16.1.
Ethics Statement
The design of the training program, including the topics covered and the format of the training, was informed by input from focus-group discussions with patient groups, learners (both pre-service and early career professionals), and HIV educators from a variety of settings in SSA, and has been previously described. [10, 14] Assessment tools to evaluate learners’ knowledge and confidence were also piloted with a subset of multidisciplinary learners before the full program was launched. All learners were given access to their pre- and post-score test results via the program’s learning management system (LMS). In addition, aggregate, site-level evaluation data were also posted on the LMS. The protocol for this project was reviewed and approved by the University of California, San Francisco’s Institutional Review Board (IRB) in San Francisco, California. Verbal consent was required at the time of participation in the study as approved by the IRB (protocol #: 19–28,447).
Results
Between May 2021 and December 2021, 5,441 learners enrolled in the training program across 18 SSA countries; of whom complete demographic and evaluative data was available for 3842 learners that were included in the analysis. Nurses (n=1172, 37.9%) and physicians (n=825, 26.7%) comprised most of the participants (Table 1). The majority (67.2%) were pre-service learners (n=2072), and 13.0% (n=401) had graduated from training within the past 12 months; 176 learners participated in the in-person course, 2790 participated in the virtual workshop format, and 774 in the online course.
Across all modules, the mean 4-point Likert score in IPC confidence increased from 2.75 pre-participation to 3.29 post-participation (difference +0.54, p<0.001). Mean IPC confidence increased post-participation compared with pre-participation across each module with the smallest gain in the module ‘End-of-life Care for Patients with HIV’ (difference +0.28) and the largest gain from the module ‘Care for an Adolescent with Perinatally-acquired HIV’ (difference +1.10). Moreover, across all demographic variables of interest, there were increases in IPC confidence (Figure 2).
At the level of the individual learner, 68.3% (n=2622) reported gains in IPC confidence post-participation, while 17.7% (n=681) reported no change, and 14.0% (n=539) reported a reduction in their self-reported confidence. In unadjusted logistic regression, female gender (odds ratio [OR] 1.19, 95% Confidence Interval [CI] 1.03-1.37) was associated with greater odds of IPC confidence gain than male gender. Relative to nursing and midwifery professions, medical professionals (OR 2.12, 95% 1.73-2.60), and pharmacy professionals (OR 1.37, 95% CI 1.10-1.70) experienced greater odds of IPC confidence gain (Table 2). Moreover, completing more than four modules in a training course was associated with greater odds of IPC confidence gain (OR 2.25, 95% CI 1.96-2.58) than completing fewer modules. Participating in in-person workshops (OR 1.56, 95% CI 1.08-2.27) was also associated with significantly greater odds of IPC confidence gain compared to participation in blended online course format.
In multivariate logistic regression, adjusted for gender, training level, country, number of course modules completed and course format, female gender (OR 1.34, 95% CI 1.13-1.59), medical professional cadre (OR 1.96, 95% CI 1.56-2.46), having graduated greater than 12 months prior to participation (OR 1.46, 95% CI 1.49-4.39), and participating in virtual (OR 1.4, 95% CI 1.12-1.76) or in-person workshops (OR 2.55, 95% CI 1.49-4.39), were all associated with significant odds of IPC confidence gain (Table 2). Learners who completed four or more course modules also experienced significant odds of IPC confidence gain (OR 2.37, 95% CI 1.99-2.83).
Discussion
Across 3842 interprofessional learners from 18 SSA countries, participating in a deliberate IPECP training program was associated with substantial gains in IPC confidence across gender, training level, health profession, country, number of course modules completed, and course format. In multivariate analysis, the odds of experiencing a gain in IPC confidence were greatest for women, medical professionals, those who participated in synchronous training programs (both in-person and virtual workshops), those who had been in professional practice for more than 12 months, and those who completed more than 4 modules. Moreover, this is also the largest interprofessional, multi-country training program aimed at improving HIV care quality among healthcare professionals in the region.[7] As such, these results have several policy and programmatic implications for the broader context of health professions education in Africa and for the provision of quality HIV care in SSA.
Firstly, this study underscores the importance of interprofessional education and collaborative practice (IPECP) in securing improved HIV care quality in programs such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) in Africa. Africa has adopted the “treat all” approach [15] to HIV care and management which requires the efforts of nurses and midwives as part of a wider interprofessional team. Programs such as STRIPE HIV that not only equip learners with knowledge but also enhance IPC confidence are critical in the achievement of both HIV-related and broader healthcare goals and targets.[16] While acknowledging that gains in IPC confidence may not equate to greater teamwork or improved clinical outcomes, these data provide compelling evidence that team-based approaches to learning in SSA can improve provider confidence, which is a critical determinant of professional practice and clinical decision-making.[1-3, 5-7, 16-19] In addition to enhancing IPC confidence, we speculate that this intervention may have enhanced institutional capacity for IPECP at participating academic institutions across SSA. As such, future analyses will seek to determine whether the STRIPE HIV program increased educators’ confidence to deploy IPE approaches in other courses.
Secondly, the findings highlight the potential value of blended synchronous and asynchronous online and face-to-face educational models to enhance IPC confidence among healthcare professionals in SSA. While synchronous formats, both virtual and in-person increased IPC confidence, in-person training was associated with significantly greater gains in IPC confidence. Accordingly, these results validate findings from other recent training interventions that have highlighted both strengths and limitations of online learning modalities for health professions education in SSA.[20-22] In addition, the findings highlight the potential trade-offs between virtual synchronous and online, blended learning strategies, both associated with smaller IPC gains in our analysis, but likely to be less disruptive to clinical care, less expensive than in-person learning strategies, and more accessible to rural/remote providers. [23-25] More research is warranted to determine how to leverage digital tools to advance IPE in SSA. Although many health professional training institutions in Africa lack access and capacity to use digital technologies to deliver HIV training, [26] our results affirm the critical role that online, synchronous training can play in advancing IPC.
Thirdly we assert that the STRIPE HIV program offers a model for how to effectively enhance IPC confidence that can be leveraged to prepare for and respond to other public health and clinical challenges in SSA.[27] Moreover, our study endorses WHO recommendations in support of strengthening IPECP initiatives as critical to achieving universal health coverage [28, 29] and delivering team-based care beyond HIV care.[16, 30] As such, future research is critical to determine whether the learning modalities employed in this study can be employed to enhance collaboration between different professions in the delivery of other clinical programs and in response to other public health threats, such as future pandemics.[3, 31]
Limitations
It is important to acknowledge limitations in the study, including self-reported confidence subject to social desirability bias, generalizability, and selection bias due to the inclusion of only those individuals who completed both pre-and post-tests, and only those who had access to the training in their setting. In addition, the study did not clearly establish whether the format of the course delivery (online vs. virtual workshop vs. blended online course) impacted learner engagement, an important consideration for future education and training initiatives in Africa. Finally, the findings do not provide evidence of improved teamwork or clinical outcomes, as these were not the focus of this evaluation. Nonetheless, they suggest that additional research, including examining the impact of IPE programs on clinical outcomes and cost-effectiveness, will be important. Evaluating the impact of interprofessional training programs, such as the STRIPE HIV program, to sustain and retain healthcare workers in clinical practice should also be a future priority.
Conclusion
This is one of the largest interprofessional, multi-country training programs to improve HIV care among healthcare professional workers in SSA. These findings highlight the importance of in-person and virtual educational platforms to enhance IPC confidence. This analysis should inform curriculum development to strengthen care delivery across SSA.
Declaration of Interests Statement
The authors report there are no competing interests to declare.
Funding
The project was funded by Health Resources and Services Administration (HRSA).
Data Availability Statement
Data included in this study are available in a public, open-access format on the Dryad dataset repository website: https://doi.org/10.7272/Q6WQ021N