Outcomes of the Expanded Programme on Immunization Pre-Service Training Initiatives in Kenya: A Mixed Methods Study

Background: The Maternal and Child Survival Program of United States Agency for International Development conducted a study in 2017 to assess the outcome of an initiative to strengthen Expanded Programme on Immunization (EPI) pre-service training. The pre-service training initiative was undertaken by the Ministry of Health (MOH) with support from partners in 2012-2016. The overall objective of the study was to assess the adoption and effectiveness of the initiative in the competency (knowledge, skills and attitude) of graduate nurses. Methods: The study included a conveniently selected sample of 14 pre-service training institutions, 23 field practicum sites, and 29 health facilities in western Kenya, and used quantitative and qualitative methods of data collection. Results: All pre-service training institutions were found to have adapted the WHO EPI prototype curriculum. Overall, tutors followed training method in the classroom as suggested in the curriculum, except evaluation of students’ learning lacked tests or quizzes. Students had opportunities for hands-on practical experience in the field practicum sites. Graduate nurses were found to have acquired the skills for vaccinating children. However, some pre-service training institutions lacked functional skills labs for practical learning of students. In addition, students did not receive up-to-date information on EPI program, and lacked knowledge and skills on monitoring and documentation of EPI coverage during preservice training. Conclusions: It appears that the EPI pre-service training strengthening initiatives facilitated competency-based EPI training of nurses in Kenya. However, preservice training institutions still have scope for improveHow to cite this paper: Hossain, I., Mokaya, E., Mugoya, I., Olayinka, F. and Shimp, L. (2019) Outcomes of the Expanded Programme on Immunization Pre-Service Training Initiatives in Kenya: A Mixed Methods Study. World Journal of Vaccines, 9, 85-98. https://doi.org/10.4236/wjv.2019.94006 Received: July 29, 2019 Accepted: August 31, 2019 Published: September 3, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
As of 2015, Kenya had 148 health training institutions, of which 102 are for nursing training, distributed in 36 of 47 counties [1]. The World Health Organization (WHO) recommended in its 2013 guidelines that health professionals training institutions should consider designing and implementing continuous training development programs for faculty and teaching staff that are relevant to the evolving healthcare needs of their countries [2]. However, recent advancements in health care science and technologies were not always incorporated into the pre-service training curricula [3]. In 2011, the WHO Africa Regional Office developed the Expanded Program on Immunization (EPI) prototype pre-service training curriculum (updated in 2015) for competency-based training in nursing and midwifery schools [4]. • To what extent has, the pre-service training institutions improved the immunization teaching and training tools.
• Are graduate nurses competent in providing immunization services once posted to health facilities after completing their pre-service education?
• What are the perceptions of graduate nurses of the EPI training they received during their pre-service education?
• What opinion facility managers and sub-county EPI supervisors have of new graduate nurses competency (knowledge, skills, and attitudes) on immunization?

Study Design
The study was a mixed-methods cross-sectional assessment. The design enabled the team to examine the outcomes of the interventions by collecting and triangulating qualitative and quantitative data from the training institutions, practicum sites, and health facilities where graduate nurses were posted; the perception of graduate nurse on pre-service training; and the perception of facility managers and sub-county supervisors on the competency of graduate nurses ( Figure 1).

Selection of Study Sites
The study was conducted in western Kenya where MCSP carried out its project

Study Population
The study population comprised 14 nurse tutors at pre-service training institutions, 28 graduate nurses at health facilities, 21 health facility managers, and 16 sub-county EPI supervisors (Table 2).    Facility managers: Managers were included were included in the study if they were officers' in-charge at the health facility where graduate nurses were posted.

Sample Selection and Inclusion/Exclusion Criteria
All facility managers were available for in-depth interview and no one was excluded.
Sub-county EPI supervisors: Supervisors were included if they were the EPI focal person at the sub-county level, responsible for supervising EPI work in the selected health facilities. All Sub-county EPI supervisors were available for in-depth interview and no one was excluded.
The MCSP data collectors visited all selected pre-service training institutions, field practicum sites, and health facilities; and interviewed all nursing graduates, facility managers, and sub-county supervisors who met the criteria.

Ethical Review and Confidentiality of Participants
The research plan was determined to be exempted from human subject oversight The MCSP data collectors obtained consent from all study participants before administering the questionnaires. Participants' names were not collected, and the information they provided was kept confidential during data collection, storage, and analysis.

Data Collection Tools
MCSP developed data collection questionnaires, pre-tested them at pre-service training institutions and health facilities that were not included in the study, and made minor changes in the tools based on the pre-test.

Data Analysis
MCSP entered quantitative data and analyzed using Microsoft Excel and generated simple frequency tables; and transcribed qualitative data into an electronic database and analyzed based on emergent themes.

Improvement of Teaching and Training Tools in the Participating Pre-Service Training Institutions
The degree to which the participating training institutions improved the pre-service training was evaluated by reviewing adaptation of EPI Prototype curriculum, skills lab, availability of reference manual, competency of tutors, and skills practice of students' in the field practicum sites. tions also varied in their degree of adaptation (Table 3).
2) Skills lab in the pre-service training institutions Six of the seven KMTCs (but none of the faith-based or private training institutions) had a dedicated room used as a skills lab for the students; one institution did not set up a skills lab due to lack of space. KMTC skills labs had limited functional equipment; for example, only one KMTC had a functioning (though old) EPI refrigerator, two had nonfunctioning EPI refrigerators, and three did not have any refrigerators (functioning or non-functioning) in their skills labs.
However, all six KMTC skills labs had a vaccine carrier, safety box, and auto-disable syringes. None of the faith-based or private pre-service training institutions had set up skills lab for the students (Table 3).

3) Availability of reference manuals
Three of the seven KMTCs (but none of the faith-based or private institutions) had a copy of the WHO EPI prototype curriculum available as a tutors' reference manual at the time of the data collectors' visit. None of the pre-service education institutions had a copy of the EPI manual available as a students' reference manual.
Probing revealed that tutors received a hard copy of the WHO EPI prototype curriculum and EPI manual (and a flash drive containing both) when they attended the mid-level managers' trainings. However, the tutors did not print out more copies of the materials and when they were transferred away from the institutions; they did not leave the hard copy of the reference manuals at the institution.

4) Competency of tutors in the classroom
Twelve of the 14 tutors (86%) observed in the classroom were found to explain the learning objectives for the topic to the students. Nearly all tutors (93%) used the suggested training methods, covered the full contents for the curriculum topics. However, due to lack of skills labs and/or functional equipment in the labs, students did not receive proper demonstration of immunization materials. Only nine of the 14 tutors (64%) evaluated students' learning using exercises or quizzes in the classroom (Table 4).  Reinforced learning by asking questions 13 93 Evaluated students by learning objectives 9 64 5) Skills practice of students at the field practicum sites Overall, all 23 field practicum sites had the prerequisites for providing students with basic skills in immunization, but there were several notable gaps.
Twenty-one of the 23 field practicum sites (91%) had such fundamental prerequisites as accommodation for the students, a qualified maternal and child health (MCH) nurse or clinical officer to guide students, immunization services, EPI cold chain equipment and commodities, and a sufficient number of clients for students to observe and practice vaccination. However, the field practicum sites of private training institutions did not have EPI standard refrigerators, but refrigerators for home use; therefore, students of these institutions did not get the appropriate practical experience on cold chain and vaccine management. In addition, two private sites were deemed unsuitable as field practicum sites because they did not have an EPI-trained staff member available to guide the students. Students at all sites had opportunity for hands-on experience in EPI cold chain and vaccine management (placing, arranging, and removing vaccines in the refrigerator; packing and unpacking the vaccine carrier; and recording the refrigerator temperature). Students in all but one practicum site were observed providing health education to mothers/caregivers. The majority (96%) of field practicum sites were visited by tutors to oversee the students' progress and practices. However, students were not universally trained in some important related skills, such as tracking defaulters and monitoring coverage (Table 5).

1) Attitudes towards caregivers
All 29 graduate nurses demonstrated a positive attitude towards caregivers (greeting them, building rapport, and treating them with respect) as observed during the immunization session.
2) Infection prevention practice A little more than half (52%) of the graduate nurses washed their hands with soap and water or used hand sanitizer before starting the immunization sessions.
The other nurses did not wash their hands because their facilities lacked running water and soap or hand sanitizer. The majority of nurses followed the non-touch technique during vaccination and discarded used syringes and needles in a safety  (Table 6).

1) Facility managers
Two-thirds (67%) of facility managers felt that the graduate nurses had adequate

Discussion
Health professional trainings must be designed as a competency-based medical education (CBME), not just as means to obtain certification [5]. Thus, students must acquire knowledge, skills, and attitude to apply in the clinical settings [6]. CBME requires an enabling environment and well-prepared teachers [7] [8].
Over the last decade, the EPI has undergone many changes, introducing new vaccines and technologies in the program and developing new strategies and guidelines to achieve high, equitable immunization coverage [9].

1) Training quality
The MCSP study found that most tutors had good knowledge of the EPI related contents and followed the training methods suggested in the WHO EPI prototype curriculum. However, there was gaps in the learning labs for demonstration of EPI materials to students. None of the faith-based and private pre-service training institutions had skills lab for students. Though most public pre-service training institutions had a skills lab, they did not have functional cold chain equipment. These gaps had consequences: MCSP found that one-third of graduate nurses lacked knowledge on vaccine vial monitors, the marker for vaccine quality. In addition, there were gaps in tutors' performance, more than two-third were not using exercise or quizzes to evaluate students' learning progress.
It also appeared that the pre-service training did not provide students with up-to-date information on the new vaccines and cold chain technologies introduced in the national program. Almost two-third of the graduate nurses did not know about the tOPV to bOPV switch (switching from trivalent bivalent oral polio vaccine) that took place in the same year of their graduation. Most preservice training institutions did not have a copy of the MOH's updated EPI ref-

Limitations of the Study
MCSP purposively selected the pre-service institutions, field practicum sites, and health facilities for this study. Therefore, findings are not generalizable to all pre-service training institutions in Kenya. Data collectors spent sufficient time at data collection sites to enable sufficient time for observations. However, the presence of the data collectors may have introduced observation bias-participants may have changed their behavior while under observation. The study's use of multiple viewpoints (tutors, graduates, and managers/supervisors) served to limit any potential bias by allowing the researchers to triangulate the quality and outcome of EPI pre-service training.

Conclusion
Considering findings from the reviews and observations at the pre-service training institutions, field practicum sites, health facilities and impression of graduate nurses, facility managers, and sub-county EPI supervisors, we can conclude that EPI pre-service training improved in Kenya and that the graduate nurses ac-