Training took place in 11 countries reaching 8797 HCW at 945 health facilities between June 2020 and October 2020. Training duration ranged from 1 to 8 days, with a median length of 3 days. Six countries relied mostly on in-person trainings while adhering to social distancing protocols and country safety guidelines whereas five countries (Eswatini, Kenya, Lesotho, Mozambique, and South Sudan) delivered trainings using a combination of in person and virtual training.
Trainees’ demographic and survey completion data are described in Table 2. Most trainees (56%) were nurses and 57% were female. Of the 8105 (92%) working at health facilities, 38% worked at primary level and 62% worked at secondary level. Those not affiliated with health facilities included staff at district or regional health offices, community health care workers, and staff from non-governmental organizations, and ministries of health (n = 661). Paired pre- and post-test results were available for 2370 (25%) trainees, and 1768 (18%) participants completed the post-evaluation training survey.
Table 3 presents the average pre- and post-test scores by country for the 2370 participants with available paired pre- and post-test data. All individual-level increases from pre to post-test were found to be statistically significant (p-value < 0.0001), and the proportion of individuals passing the assessment at a score of 70% increased in all countries. On average, participants increased their score from pre- to post-test by 15 percentage points (95% CI 0.14, 0.15). Participants from Burundi made up the smallest country cohort (n = 74, 3.1%), yet had the greatest improvement from pre- to post-test, with an average increase of 42 percentage points from pre- to post-test (95% CI 0.39, 0.45). Participants from Kenya made up the second largest country cohort (n = 350, 15%) and scored higher on both the pre- (average pretest score = 80%) and post-test (average post-test score = 89%) than participants from any other country (Table 3).
Performance across participant demographic characteristics varied by cadre, facility type, and sex. As noted in Table 4, the largest cohorts were nurses (n = 857) and females (n = 1307). Overall, doctors had the highest pass-rate in the post-test (n = 193), with 84% of all doctors passing at or above 70%. Nurses had the second highest pass-rate in the post-test (n = 559), with 65% of all nurses passing at or above 70%. Nurses also demonstrated a large average improvement from pre to post-test (19 percentage points). There were no statistically significant differences in gain scores comparing HCW from primary (N = 1314) to secondary (N = 653) facilities (Pr > Z 0.1988), females (N = 1307) to males (N = 603) (Pr > Z 0.1524), or nurses (N = 857) to doctors (N = 229) (Pr > Z 0.116); however, there were statistically significant differences in gain scores comparing all cadres using the Kruskal–Wallis Test (p = 0.008, 3 DF).
Post-training survey results
Overall, 1768 participants across the 11 countries responded to the post-training survey (Table 2), the largest proportions of which were from Malawi (18%) and Kenya (17%). The majority of respondents were nurses (55%). Thirteen percent of respondents had less than 1 year of professional experience, 40% had 1–4 years, 24% had 5–10 years, and 23% had more than 10 years. The majority of respondents attended an in-person training (60%), while 14% attended via live webinar, 13% via a combination of methods, 7% through self-study (distance learning), and 6% not specified.
When asked about their satisfaction with the training, of 1560 respondents who answered the question, 1344 (87%) were extremely satisfied or satisfied with the training, while 139 (9%) were neutral, and 77 (5%) were dissatisfied or extremely dissatisfied. For assessment of training duration, among 1560 respondents, 692 (44%) felt that the training was an appropriate amount of time, while 71 (5%) felt it was too long, and 797 (51%) felt that the training was too short. When asked about relevance of training to their daily responsibilities around COVID-19, out of 1569 respondents who answered the question, 1411 (90%) found that the training was extremely relevant or relevant, while 83 (5%) were neutral, and 63 (7%) thought it was not relevant or was extremely irrelevant.
In rating their ability to perform specific IPC-related activities following the training (Fig. 2), the majority of participants indicated that they could either teach others or do the activity independently, with the highest ability ratings in use of IPC checklists, ensuring adequate IPC, including prevention of infections among health care workers, and preventing nosocomial transmission within health facilities (78%, 78%, and 77%, respectively, could teach others or do the activity independently).
Overall respondent confidence in their ability to respond to COVID-19 was high following the training. Among 1572 respondents, 86% were confident or extremely confident in their ability to communicate with community leaders about COVID-19 and to rapidly respond to rumors and myths. Of 1309 respondents, 84% were confident or extremely confident in their ability to communicate with health facility managers about COVID-19 and to rapidly respond to rumors and myths. Among 1271 respondents, 85% were confident or extremely confident in their ability to address COVID-19 at their health facility using the skills and knowledge gained from the ICAP-supported training. And of 1226 respondents, 83% were confident or extremely confident in their ability to continue providing non COVID-19 specific care at their health facility using the skills and knowledge gained from the ICAP-supported training.
Respondents reported that the main barriers limiting their ability to respond to COVID-19 at their health facility included lack of access to testing kits for COVID-19 (55%), lack of access to PPE (50%), limited space in the facility to isolate patients (45%), lack of access to technical equipment (43%), funding or budget constraints (42%), understaffing (39%), and lack of motivation from staff (38%).
Respondents felt that the topics most applicable to their contexts included IPC training on standard and droplet precautions (76%), recognizing COVID-19 signs and symptoms (72%), donning and doffing PPE (61%), and effective communication and community guidance for COVID-19 (59%).
Responses from open-ended questions showed that participants wanted additional training on COVID-19 including refresher courses and trainings on relevant updates around the disease, additional trainings on case management and clinical care, and access to the training materials for future reference. Other themes identified in the open-ended questions included the need for simulation-based training, especially around donning and doffing PPE, as well as the need to expand the training to non-clinical facility staff.