 Fabulous! So now it is my great pleasure to welcome our three speakers or our three presenters, Astrid, Heben and Salamowit. Astrid is in Denmark and Salamowit and Heben are in Ethiopia and they are currently having an occasional problem with connections and sounds so we will just go for it and see what happens. They work for the Montmaternity Foundation and I'm really interested in listening to this because it uses a hybrid method of educating and they're going to tell us all about it. So over to you to introduce yourselves Astrid. Thank you very much Linda. So yeah, my name is Astrid Grundweig and I'm a research and learning officer in maternity foundation based in Copenhagen and today I'm presenting with Heben and Salamowit will see if Heben's sound works now and then she will start the presentation and Salamowit will be with us to respond to questions on the side and also take part in the discussion at the end. But I think we are still having some issues with the sound coming through from Heben in Addis. So I will continue and then hopefully the sound will improve along the way. Yes, do go ahead and try every so often but then we'll see how it goes. I think there's a delay as well. I have a feeling there's a delay. Okay, well we see and so today we're presenting to you some of the findings from this ENC now a feasibility and effectiveness pilot study that we did of four different training approaches of the same ENC now content which was the content developed by Lerdale and AAP in the line of COVID-19 taking the traditional ENC content and adapting it for an online format and the maternity foundation implemented these four different training modalities in Ethiopia. So yes the core content was the ENC now content. Heben, are we hearing you now? I don't know if you are. Yes, please proceed. Thank you very much and sorry for the disruption and thank you Astrid for filling up for me. Yeah, we are here to present for you today about the ENC now pilot project we were having with Lardale Global Health and AAP. It's a curricula adopted from online training developed by these two huge organizations and it's focused on the essential newborn care management. So management of birth asphyxia including the BNB exercises. So this ENC online training was conducted from May to October 2021 in Ethiopia as is in one of the regions in the Amhara region which is nearby to Addis Ababa called Debra Bohan and we were conducting this pilot study in 18 health facilities and in total we were having 59 participants who took part on this ENC now pilot. So the training approach was a blended learning with an online lecture and on-site exercise with the on-site facilitators and clinical practice and at the same time we used the virtual methods like telegram to do exercises. So the materials and tools we used during this the ENC approach is the online ENC slide text and there was a flip chart presentation used and peer-to-peer clinical practice on-site and then the neonatal mannequins from Lardale Global Health Work used to do the simulation practices and self-deliver application from Maternity Foundation was also integrated when the trainings were being provided and also when the participants are routinely exercising on their daily routine life. So the facilitators where there were two types of facilitators the TOT trained remote master trainers they were trained by Lardale Global Health and TOT trained on-site facilitators which were also trained by the master trainers. So we have of today one who can facilitate on-site and the others were from remotely or virtually by the master trainers. So this the ENC now training or the pilot training has four approaches we were dividing these facilities and the health care professionals in four categories and we were implementing this the first two they were using the traditionally structured one-day ENC course like a full-day ENC course which was delivered by the master trainers online and it was supported by the on-site facilitators in were present in the facilities and then this one day the longer training the traditional type of training was supported by stream and self-directed learning and which was also encouraged and facilitated through the virtual approach like on a telegram group they were given some exercises to conduct and then they were sharing for the larger group and the other facilities who are also a team member in the telegram group so these exercises were conducted and posted. So this approach was used for the first two groups the R1 and for R1 and R3 and then the difference between R1 and R3 was one of the arms I mean R1 and R2. R1 uses the SDA integrated slide decks and also on their clinical practice like the streamers self-directed learning was also supported by the safe delivery application and when we come to the R1 the second R they use the longer approach but the safe delivery application was not integrated so when we come to the third and fourth arms and arms for our delivered the ANC course and then a spaced out approach like the portion of the trainings were divided into five and then every two weeks they took a session which will last like a moderately three hours and then for arms 3 the safe delivery application was also integrated throughout the course time and for arm 4 the safe delivery application was not integrated and these also the second I mean the third and the fourth arms were also given exercises to post on the telegram group and like everybody was motivated throughout the three months time period when they conduct when we are conducting the this ANC pilot. So we were trying to see two things one the the effect of like between the spaced out trainings and the older method like the one time longer training and also the second thing we were trying to see is the integration of the safe delivery application in the retention of knowledge and skill for these four groups so that the study design is a mixed approach we were trying to see the feasibility and effectiveness of the approach and we use qualitative and quantitative tools so at the start of the pilot study a background survey for the participants characteristic like was conducted baseline and in-line follow-up assessments or also conducted they were assessed for sorry knowledge on the ANC and the skills was measured by the OSCIS conducted by the on-site facilitators using the back and mask ventilation and self administered confidence assessment test was also filled out by the participants this was used as a quantitative tool and beside this OSCIS and knowledge and skill assessment we were also having a rapid facility review at the follow-up time to see the improvement of the changes which have been brought after the training based on the skill and knowledge of the participants so as a qualitative tool a feedback survey with participants and the facilitators in-depth interview for selected like sample participants and a focus group discussion with the on-site facilitators was conducted and the health facility managers were also assessed for a rapid feedback survey to see what they have observed after the training and this follow-up study so this was the tools which we used to assess so when we come to the participant characteristic as I was mentioning we were having 59 midwifes and other health workers from these 18 health facilities in North Zard Shoah so when you see a majority of them were like midwifes and from the 59 58 were midwifes and one clinical nurse involved in the at the baseline assessment 70 percent of them were female and 30 may 30 were male when we see the average age for the participants was 27 with the minimum of 22 years and maximum of 40 years of the participants and from the 59 participants 68 percent of them had a smartphone which was used to to install the safe delivery application and they were using throughout the time so when you see the clinical year of experience for this participant it ranges from one year up to 10 last years so majority of them were having experience like two to five years which were account 47 percent of the participants then followed by five to ten years experience which accounts 28 percent and around four percent of them have 10 plus years experience and 13 percent of the participants were having around one year less than one year experience in their clinical practice so the other thing at the baseline which we assessed was for trainings they took in the past six months before our study starts and 21 percent of the participants responded that they did a training a priority but mostly it was family planning and other trainings but not the ANC training and only one participant responded that they have a remote training history or experience before and none of them had a training experience at the facility which was conducted on site in the facility in the past 30 days prior to our baseline assessment or our study begins yeah on the retention of our participants mostly we say we were successful on retaining the participants but some connectivity issue was a challenge for Wi-Fi connectivity was a challenge mentioned by the participants and at the beginning of the study we were having 50 some participants in the in the line it declined to 50 and in the follow-up time which was conducted after three months we were having 44 participants so there were a little dropouts and when the Gleason 4 dropout of participants were assessed mostly it was because the participants were transferred to other health facilities where we were not conducting the assessment or this pilot study was not part of and the other bigger reason for leaving or not participating in the follow-up time was because of a maternity leave some of the female participants gave presents they were in maternity leave so from baseline to inline we lost seven participants due to these reasons and then from inline to follow-up six participants were lost so at the end of the follow-up there were around 44 participants in this study so was it feasible to implement all the approach and the other key points will be discussed by my colleague Astrid thank you for your time over to you Astrid thank you very much Kevin and how happy I am that the connection came back and so I will share with you some of the results from the data collection that we have done across different participants in the project and first we're sharing a bit from the master trainer's perspectives where we found that it is possible and feasible to deliver the remote version of the ENC training both in the short version and the spaced out version however it was observed that the short and intensive full day is can be challenging because it requires a lot from the learners that they need to absorb all the content in one day and a full day of Zoom trainings can be really tiring and thus a higher risk of losing the participants attention and on the other hand we found that the spaced out sessions worked quite well but maybe the five sessions were too much and and we'll have to really think about with refining how they were spread out into two different sessions and the safe delivery app was integrated into the package and and that was found feasible from the perspective of the master trainers they were able to integrate relevant videos from the safety delivery app and also guide participants to do certain exercises in the app and it provided this bridge between the online training and also the self-directed learning and we also learned that well despite having tested the internet connectivity in Ethiopia we know there are certain challenges and sometimes on the day it just doesn't work very well for a while as we also saw today and and it's important to really try to test it as well as possible before and also have backup options which for this training the very good facilitators were a key part because they enabled some kind of continuation even when the the connectivity challenges were really massive and what was also observed by the master trainers is that it was important to ensure that the healthcare workers in the facilities actually have dedicated time off to participate whereas it was put out for the facilities to decide how they wanted to participate but some healthcare workers or midwives had to both kind of attend to the case flow at the facility and try to participate at the same time which led to some interruption in the training participation we had included the self-directed learning component to introduce this mixed training modality approach and had a very detailed weekly schedule had been developed by the master trainers to support and and reinforce the learning that had taken place in the session so in the content and what we found when we tried to to have a look at whether there was high participation or not we found that it varies quite a bit at the each of the arms the participants were requested to share back in the group when they had conducted the exercises and share videos or images of them doing the drills and the like and what we saw across the groups is that there was huge variation in is in some of the facilities they didn't share any activities and in others it was up to 70 percent of all the activities and if we did find that within the group so there was high participation initially it seemed to be contagious and more and more facilities decided to join and share back some some of their experiences but it was also a challenge maybe to maintain the participation level over the full three month period and what we also learned from the interviews is that the internet connectivity was also a discouraging factor because participants said they were not able to upload images or videos and there we should for next time also think about how just to encourage participation in in written form and but generally from those who participated they found the messages very helpful and and not annoying because it helped them stay on track with the learning and it motivated them to help to continue working on the exercises and and some also mentioned that they continued practicing and doing redoing the exercises until they got them perfectly well and felt that they want to share them in the group and we they were also the feedback was also that they were helpful in terms of of reminding you to continue doing the exercises which helped retain both the knowledge and skills and at the end line we collected feedback from the participants about their training experience and what we found was that generally across the both both approaches there was a quite a high level of satisfaction with the training approach and the tools and for many it was a novel experience they had not participated in a remotely delivered training before and also found that the mix between the online training and and the offline exercises and drills at the facilities as well as the weekly exercises was a good combination and the safe delivery app was also well received by the two arms where it was integrated and they find it helpful that they can review the videos and the clinical practice cards at their own time for extra revision and it was again also emphasized this challenge about timing and and that it was challenging to manage case caseload whilst also taking time off to participate that would be something that needs focus for next training and there was a dissatisfaction expressed with the PDM because at the receiving the training at the facility came with a and at facility PDM which is quite different from the PDM sometimes received when going outside the facility to participate in training and and that was we also mentioned quite a few times but at the end after the training had been completed and the participants had seen the benefit they say they would also like to receive this type of training and at the time because they found it quite helpful and what some one participant also pointed out that it was a very inclusive way of receiving the training because everyone or several health care workers at the facility midwives participated whereas other times it's a training that takes place outside the facility and only the senior midwife or the facility manager goes to receive the training and again we have also heard that some would still prefer off-site training to be able to concentrate fully so there's still some unsolved issues we interviewed both facility managers and the facilitators and largely they their feedback echoes both that of the the participants and also the master trainers and they found that it was a relevant and well-structured training and that the tools and and the experience was generally good the issues around wi-fi interruptions or lack of smartphones among the participants were observed as challenges and and also the training during work hours but it's worth bearing in mind that tablets were delivered to each the facilities to both allow the participants to connect during the trainings but also to do exercises on a continued basis using the facility tablets to try to bridge the issue of individual smartphone ownership so when we try to explore we have a small group and as you as heaven pointed out there was a drop in participation so our results are indicative but we'd like to if we have the possibility to scale up to explore the results at a larger scale but what we see from the the assessments that we're done at baseline end line and follow-up is that generally there was a overall an improvement in the knowledge a quite a high one from the baseline to the end line where we saw that in the at the baseline around 30 percent past the ENC knowledge test following the existing criteria and that was up to 70 percent at the end line and our results indicated further improvement at the follow-up to 80 percent who passed the the knowledge assessment and there are some variations across the arms but generally there was an improvement from baseline to end line quite high and in some cases a further improvement for the follow-up except for in arm one but that's also a particular because we faced some challenges on the ground and a different team of of assessors of facilitators went to do the follow-up assessment also at a delayed time due to insecurities on the ground so we had to delay the whole process and but generally this there wasn't a strong improvement in the knowledge from baseline to end and overall it was maintained at the follow-up which for us is if something we keep in mind because often we observe a drop in the retention of knowledge when we do a follow-up three to six months later that is what we've experienced in a lot of other training initiatives we have conducted in Ethiopia what we also saw is that there was a positive effect on the confidence we tried to assess confidence in in ENC related tasks and there was also a as a overall a significant increase from the baseline to end line and again we saw this sustained at the follow-up and one participant also kind of puts it into perspective and explains how they when they faced an asphyxiated newborn before there was fear and it was difficult to resuscitate but now the training has helped them manage complications so that's very promising and similarly we saw with the skills and increase and the high retention and and we saw again the shift from around 30 percent passing the the oski b case scenario of the ENC course content up to 75 percent passing the skill scenario and 75 percent of the participants well pasted both end line and follow-up and also when we checked the basket we used the bag and mask ventilation check and those nine steps in that assessment we also saw an increase from around 43 percent overall being able to conduct this bag and mask ventilation check at all the steps up to 68 and at the follow-up 70 percent and so generally it is high retention and at the follow-up level again with some variations across the arms that will we're working on exploring a bit further looking not across all four arms but really about into the results of the short and intense training versus the spaced out training the training took place at the facilities and we are required we're quite interested and excited about these results where we asked at the follow-up whether any kind of exercises had been done or training initiatives by the participants at the facilities in the 30 days prior to the follow-up which is a well way after the core training had ended and what we see when we ask that question is that in there was a high increase from no one responding that they had done any exercise at the facility prior to the baseline it was up to between 25 and 93 percent of the respondents across the facilities who said so at the follow-up point and one participant also explains that they took what they learned in the training and they trained two other midwives and for the nurse they also demonstrated and showed them how to resuscitate because in case of a work overload anyone should be able to help the babies breathe and or resuscitate them so they took what they learned in the training and passed it on to other colleagues at their facilities which is an encouraging and surprising results for us from this training and when we in the interviews explored whether this training had been practical and they had been able to put the knowledge and skills taught into practice this is an important point for us because we are aware that sometimes the knowledge and skills learned in a training doesn't necessarily carry over into practice so we spend a bit of time exploring this and generally there was feedback that it was very practical and they were able to take what they learned and put it into to practice and act in case of complications and one participant also explains that we now do the job manage as fixed here without any difficulty and the on-site facilitators also mentioned that they saw this practice improve during their repeated visits and the facility managers again also echoed this that they say that their practice had and performance had changed and improved as a result of the training so we'll just jump to the conclusion before we love to hear also from all the participants listening in today about their experiences with remote trainings what we found is that it's possible to do the remote version of the ENC now training with the self-directed learning component but it requires quite a bit of preparation and it's very important that there's dedicated time off for the learners and good internet connectivity or very good alternatives in case the connection breaks and we found that trying to establish this community of practice on telegram which would be a supporting component to the training and was intended to help reiterate training and increase retention through a social learning experience was challenging to maintain throughout but it's clear that some participants found it very useful and helpful and benefited from it a lot so we are trying to further explore what what were the key factors that made it work very well in some groups and maybe a little bit less well in other groups we found that the safe delivery integration was feasible and could serve as a helpful add-on especially because it works completely well offline so when when the connectivity was challenged and some of the online tools for this training didn't work the safe delivery app was still functioning the spaced out trainings were well received by many participants but we found it's necessary to refine the session structure a little bit and overall the results also point towards higher retention from the spaced out trainings but this is also something we are exploring further and we learned that it's important to address the question around expectations per diem expectations upfront and explore other ways to incentivize a participation one option that we discussed but wasn't included in this training was to ensure that CPD points are credited this is something we have achieved in other projects and initiatives in Ethiopia and something we'll also explore going forward and we overall see that the remote training can effectively increase knowledge and skills and whether it's the short and intensive combined with the self-directed learning or the the spaced out combined with the self-directed learning the results are promising and overall the retention at three months follow-up is quite high and and then we have all this feedback that points towards a very interesting and sustained change both in terms of maybe there's an indication that supported establishing a bit of a community of practice at the facilities where yeah with the mannequins and with the tools at the facilities the participants in the midwives also empowered to pass on what they learned and and train other colleagues and that because it took place at the facilities and it was very practical it's impossible to to implement the changes in the practice straight away so with that I think we'd like to hear from all the all the colleagues who are listening in if they have had other experiences and what their thoughts are thank you so much thank you very much Astrid and heaven could I hand this stage over to my colleague Juliet who is shadowing me as facilitator in this session and she'll help with the questions I'm going to put a question straight away in the chat over to you Juliet thank you so much and thank you for a really interesting presentation yeah it's there's so much to absorb but in quite a short time but it was really interesting so Linda's question I'll just read it out for for everybody have you considered teaching these skills to the whole multidisciplinary team for example the doctors as well which might help build a team build in where Linda reckons it might do that had you had you considered that Astrid or heaven pardon can you repeat the question please yes had have you considered teaching the skills to the whole multidisciplinary team so including the doctors as well for example to try and help build the sense of a team okay so this pilot study as we were earlier mentioning was conducted in the health centers so in those health centers there are the nurses the midwives and health officers who are working in the facility and this pilot or the training includes everyone who is working in the msh department who are in close contact with the mothers and the newborns so they were taking part on the training so yes actually there were no doctors in the facilities but the rest of the team who was available and working in the health facilities was included and the peer-to-peer learning session after the cascading of training by maternity foundation with the remote facilitators they were transferring their skill and knowledge for their colleagues in the health facilities if I answer your question correctly thank you thank you yes yes so you it was it was including everybody who was there although you didn't happen to have doctors in in the health facilities lovely thank you there's a question from Sheila clone morning Sheila I know Sheila from a vault so Sheila's asking what role did the onsite facilitators play and was this linked to the training times only or throughout the first three months what is the role of the onsite facilitators so the role of the onsite facilitators is to co-facilitate or train the midwives or the healthcare professionals who were part of the training and in the health facility it was a two type of approach as I was mentioning so remotely via zoom we were providing the training with the slide decks and then these onsite facilitators are present in the facility they are from and nearby other facilities hospital teaching institutions and their master trainers also so they were supporting the team on one facilitating the training the second is when there is a clinical practice or when hands-on skill is involved like even though we are following virtually they are there in the in the facility to assist or coach the participants on conducting the skills or the practical stations and then they are also giving them feedback for what they were doing in the facility and they are also part of the telegram group to motivate and encourage the participants to conduct all the skill assessments like I mean skill practices they are conducting and then sharing for the larger group and they were supporting them throughout the three months the process not only only in the actual training time but also throughout the time where we were conducting the assessment and the whole pilot thank you very much okay so they did have an ongoing role for sure and a sort of encouraging role as well to keep the motivation going it sounds like from what you're saying yes sorry one thing I forget that beside the encouraging role and the coaching role that they have also when we were conducting the skills assessment in the baseline and at the end line in the follow-up time also they were involved would like to do the skill assessment to see the improvement pre and post skill assessment also conducted by the on-site facilitators for the participants okay so was that the same facilitated throughout the whole trial as it were was it the same one who did it at the beginning and partly throughout the end or did the did you have different facilitators yes so at the beginning of the training or when we start like for the four arms we have 18 facilities so for this 18 facilities one on-site facilitator was assigned for each one and and this onsite facilitator like continues throughout the time like similar facilitators yes was used to do the baseline assessment the in-line assessment in the training times even for the interrupted arm tree and an armor for trainings like when we do five substations of the training similar facilitators were visiting the health facility to do and each group has its own facilitator not to mix up and you know to have a proper follow-up for each one we are trying to minimize the bias by retaining the facilitators at each facility okay thank you she just made a comment in the chat there talking about the challenge of being able to build in sustainable strategies excuse me and I was wondering whether you felt that the um safe delivery app was part of that um approach to try and you know it was sort of resource that was ongoing as you say both able to be used online and offline so it's kind of cement learning in a much longer term way is that why that was developed uh yeah um with your question you have also given the a little bit of the answer the safe delivery application is um a tool which is developed by maternity foundation which Karnas is a healthcare professional not only midwifes but any skill birds that enhance on like developing their skill and retain for retaining their knowledge so it has different topics like there are video section cards practical procedures and there is a my learning session which they can also be certified by answering and answering your questions which is in the app and at the end they can be certified this was also part of the in the file it where the safe delivery application was integrated for the two of arms and that is also one way to keep the sustainability and the other is these four arms as I as we were earlier mentioning they have a telegram group for each arm and then in the at the first stage the telegram group was used to communicate among the arms so each arm like have four to five has the facilities different heads facility so they share experience in the from their facilities and then participants who are working in that facility can be added at any time even they are keeping the telegram group until now even though the pilot project has ended we are also in that group and we can see like when people are trying to motivate themselves and share their experience some of them they post their certificate when they finish their my learning from the safety delivery application some of them they post that they have managed some of the baby and they are overcoming the challenge from what they get from the training and the legs for retaining all sustainability the telegram group is helping and the other the safety delivery application they have it on their hand and the smart with the smartphones so so that is for sure helping very much on retaining the knowledge skill and also the the program lovely thank you thank you so much I think we probably need to finish because well our time is nearly up I'm sure we could carry on this discussion with quite some time what's an amazing project