|Year : 2014 | Volume
| Issue : 3 | Page : 136-146
Effectiveness of train the trainer module in delivery of HIV prevention messages for Homoeopathy and Ayurveda practitioners
Divya Taneja1, Adeline Nyamathi2, Anil Khurana3, N Srikanth4, Chaturbhuja Nayak5, MM Padhi6, Maya Padmanabhan7, Richa Singhal8
1 Research Officer (Homoeopathy), Central Council for Research in Homoeopathy, New Delhi, India
2 Professor, University of California, Los Angeles (UCLA) School of Nursing, USA
3 Deputy Director (Homoeopathy), Central Council for Research in Homoeopathy, New Delhi
4 Assistant Director (Ayurveda), Central Council for Research in Ayurvedic Sciences, New Delhi
5 Former Director General, Central Council for Research in Homoeopathy, New Delhi, India
6 Deputy Director (Technical), Central Council for Research in Ayurvedic Sciences, New Delhi, India
7 Statistical Assistant, Central Council for Research in Homoeopathy, New Delhi, India
8 Statistical Assistant, Central Council for Research in Ayurvedic Sciences, New Delhi, India
|Date of Submission||03-Dec-2013|
|Date of Acceptance||25-Sep-2014|
|Date of Web Publication||25-Sep-2014|
Research Officer (Homoeopathy), Central Council for Research in Homoeopathy, 61 65, Institutional Area, Opposite D Block, Janak Puri, New Delhi 110 058, India
Source of Support: This study was funded by the World AIDS
Foundation, No. WAF 324(03-046),, Conflict of Interest: None
Introduction: A 2-day training program was developed to train Homoeopathy and Ayurveda practitioners to impart HIV/AIDS prevention messages to their clients. The purpose of the study was to evaluate the effectiveness of this training program based on train the trainer modality.
Materials and Methods: Ten primary participants were enrolled in each one day and two day training program. Both the groups were instructed to impart further training to 10 participants each. The knowledge of and attitudes toward HIV/AIDS were measured in primary participants before and immediately after training and at the end of 3 months and in secondary participants before and immediately after training by a 21-item questionnaire.
Results: In 1-day group, the pre-training and post-training assessments were completed by all the 10 participants, where as the 3 month assessment was completed by only seven participants. In this group, mean overall knowledge score was 15.9 which increased to 17 post training and reduced to 16.7, 3 months post training. In 2-day group, the pre-training and post training assessments were completed by 10 participants, where as the 3 month assessment was completed by nine participants. In this group, the pre-training score of 17.4 increased to 19.8 immediately after training and decreased to 18.4, 3 months after training. From the 1-day group and two day group, seven and nine participants respectively, conducted secondary trainings. In case of secondary trainees, the cognitive knowledge scores showed a statistically significant difference before and after trainings in both the groups.
Conclusion: The training module on HIV/AIDS was useful in enhancing the knowledge of physicians of Homoeopathy and Ayurveda on cognitive and transmission related aspects of the disease and on its ethical, social and legal implications. With such training programs the homoeopathic and ayurvedic practitioners can play a vital role in prevention of HIV infection by undertaking appropriate patient education and counselling.
Keywords: Ayurveda, Educators, Homoeopathy, HIV/AIDS, Physicians, Train the trainer
|How to cite this article:|
Taneja D, Nyamathi A, Khurana A, Srikanth N, Nayak C, Padhi M M, Padmanabhan M, Singhal R. Effectiveness of train the trainer module in delivery of HIV prevention messages for Homoeopathy and Ayurveda practitioners. Indian J Res Homoeopathy 2014;8:136-46
|How to cite this URL:|
Taneja D, Nyamathi A, Khurana A, Srikanth N, Nayak C, Padhi M M, Padmanabhan M, Singhal R. Effectiveness of train the trainer module in delivery of HIV prevention messages for Homoeopathy and Ayurveda practitioners. Indian J Res Homoeopathy [serial online] 2014 [cited 2019 Sep 19];8:136-46. Available from: http://www.ijrh.org/text.asp?2014/8/3/136/141734
| Introduction|| |
The train the trainer approach is widely used in various public health programs because of higher resource efficiency ensuring a larger outreach. However, the transfer of messages has to be consistent throughout the process so as to ensure program effectiveness. Central Council for Research in Homoeopathy (CCRH), an autonomous body of Ministry of Health and Family Welfare, Government of India, prepared a training module for training of ayurvedic and homoeopathic practitioners and educators in delivery of HIV prevention messages to their clients and students. This module was formed in collaboration with the research team from University of California, Los Angeles (UCLA). The 1-day module focused on the clinical and medical knowledge aspects of the disease and its prevention. A 3-day module was developed to encompass legal, ethical, social issues associated with the HIV disease and on the behavior change communication so as to enable the practitioners to deliver the prevention and HIV counseling message effectively to their clients. Both the modules were successfully tested on more than 200 ayurvedic and homeopathic practitioners in Delhi. Findings of the study  revealed that both the one and three-day primary trainees significantly increased their HIV/AIDS knowledge and attitude scores from pretest to immediate post test with ongoing improvement in both groups over the 3 and 6-month period. A total of 26% of primary trainees in the 1-day and 36% of primary trainees in the 3-day program trained secondary trainees. This program was independent of the National AIDS Control Program in the country and focused on identifying a strategy for capacity building of Ayurveda and Homoeopathy practitioners, only.
It was important to identify an optimum duration, where in the training objectives are achieved, while at the same time, the regular functioning of the practitioners is not affected. Subsequently, CCRH, while keeping the same components, reduced some activities and compacted the 3-day module into a 2 day training module of 12 hours duration. A study was undertaken to evaluate the effectiveness of this training program based on train the trainer modality. The module was, therefore tested in comparison with the 1-day training module (6 hour duration) to identify its effectiveness on the primary and secondary trainees. Assessing the knowledge and attitudes of the primary and secondary trainees on an identified questionnaire, before and after training, tested the effectiveness of the train the trainer methodology.
| Materials and Methods|| |
A culturally-sensitive HIV/AIDS education and training program of 1- day duration and of 2- day duration was developed. Participants were randomly assigned to the two groups and in each group 10 participants were trained. Both the groups had both ayurvedic and homoeopathic practitioners and educators. No distinction was made between the ayurvedic and homoeopathic practitioners, and the training focused on risk assessment and delivery of HIV prevention message to the patients/clients rather than on the treatment aspect. Knowledge and attitudes of primary trainers thus trained was assessed using a 21-point questionnaire as developed and used in the previous studies during the development and testing of HIV/AIDS training module by the CCRH in collaboration with the UCLA. , This assessment was done immediately before the training, immediately after the training and at 3 months after the training. The participants were encouraged to conduct further training sessions of 10 participants each (secondary trainees) and the knowledge and attitudes of these secondary trainees was assessed using the same 21-point questionnaire, immediately before and immediately after the training. The research study was approved by both the Scientific Advisory Committee of the CCRH and the UCLA Human Subjects Protection Committee.
Sample and setting
The training sessions for the primary participants were organized by CCRH at its Regional Research Institute for Homoeopathy (RRI), Mumbai. The qualified practitioners as per the regulatory requirements of India were identified through two homoeopathic medical colleges, one ayurvedic medical college and practitioner associations in Navi Mumbai. Out of 26 practitioners who responded and agreed to participate in the study, 24 were chosen randomly and allocated in the 1-day and 2-day groups using simple random number allocation. Ten participants in each group were invited for the trainings and training dates were informed in advance.
The importance of conducting secondary training was emphasized in both the groups and the participants were encouraged to conduct secondary training sessions and apply the assessment questionnaire to their participants. The primary participants recruited secondary participants by convenience sampling to conduct their training sessions.
The Indian members of the research team from Delhi, three members which had conducted the 1-day and 3-day trainings in the previous study  were again involved in conducting the training. A counselor from Mumbai was additionally involved, to conduct a half day (2 hour 30 minutes) session on counseling and behavior change communication for the two day training participants which ensured that role plays were conducted in local languages and local sensibilities were taken into consideration.
The Delhi team, prior to the training sessions, explained the objective and the procedure of the study and took written informed consent from the participants. The pre-training and immediate post training assessments were made at the beginning and end of the training session. Assessment at the end of 3 months was made by postal communication.
The primary participants thus trained conducted the training session of 1 day (6 hours) duration for 10 participants within 1 month of the training. These secondary trainees were also informed of the objectives and procedure of the study and consent was taken from these secondary trainees. Pre-training and a post training assessment of these secondary trainees was applied by their respective primary participants.
Primary training sessions: One day and two day
The 1- day training session was of 6 hours duration and covered topics on epidemiology of HIV/AIDS, HIV virus, transmission of HIV/AIDS, natural history of HIV diseases, clinical manifestations and opportunistic infections, laboratory diagnosis, management of HIV positive persons, role of alternative systems of medicine, prevention of HIV/AIDS and case studies. The 2-day training session was of 12 hours duration. In addition to topics covered in the 1-day training program, sessions on personal, social, legal and ethical issues related to HIV infection were also conducted [Figure 1].
The learning methods adopted were open discussions, case scenarios, etc., to maximize participant interactions and understanding of real life situations [Text box 1].
An HIV counselor conducted a detailed session on behavior change communication. Role plays related to HIV counseling and prevention were conducted by the participants in groups to encourage self-learning and discussions [Text box 2].
Prevention of HIV/AIDS was discussed using culturally sensitive case scenarios such as "A mother comes to you for taking medicine to prevent pain while getting her daughter's ears pierced (a practice common in India), what advice will you give her?" This scenario, for example, identified the risk of infection associated with sharing of infected needles and use of unsterilized needles. Case discussions and role plays on personal, social, legal, ethical issues and HIV counseling and preventions were conducted [Text box 3].
Secondary training sessions
The secondary trainings were similar to the one day training conducted and had sessions on epidemiology, virus, transmission, natural history, clinical manifestations and opportunistic infections, laboratory diagnosis, management, prevention, case studies and role of alternative systems of medicine.
Power point presentations and a booklet of resource material were given to the primary trainers to conduct these sessions. The primary trainers were free to adopt any method of training, participatory or lectures.
Socio-demographic characteristics, collected on a form designed for this purpose, included gender, education, age, system of medicine (Homoeopathy or Ayurveda), and site of employment and are reflected in [Table 1]. Knowledge and attitudes were assessed on a modified 21 item Center for Disease Control (CDC) questionnaire.  In a previous study conducted in India, the internal consistency (Cronbach's alpha) of the overall knowledge scale when used with physicians of Homoeopathy was 0.81 and the internal consistency for the knowledge of transmission subscale was 0.88.  The possible range for the overall scale was 0-21 while, cognitive and transmission scale range, 0-10 and 0-11, respectively. The subsequent assessments were a retest of the same questionnaires.
Within the two groups of primary trainers, changes in overall AIDS knowledge, and in the cognitive and transmission subscales, between pretest and post test were examined with repeated measure Analysis Of Variance (ANOVA). Changes in scale scores across the three time periods for both groups were assessed by multilevel linear regression analysis controlling for age, gender, and practice site. The changes in knowledge and attitude scores are reflected in [Table 2] and [Table 3].
|Table 2: Knowledge scores of all one - day and two-day primary trainees |
Click here to view
Within the secondary trainees of these two groups, changes in overall AIDS knowledge, and in the cognitive and transmission subscales, between pretest and post test were examined with paired t-test and are reflected in [Table 3]. The statistical analysis was done using SPSS version 20.
| Results|| |
The mean age of the practitioners in the 1 day group was 30.2 years (SD = 4.37, Range = 23-39 years) and in 2 day group was 32.7 years (SD = 6.42, Range = 25-42 years). The number of male participants was more than female participants. Almost all the participants were practicing in clinical settings.
In the 1 day group, the pre-training and post training assessments were completed by all the 10 participants, where as the 3 month assessment was completed by only seven participants. Mean overall score was 15.9 which increased to 17 post training and reduced to 16.7 at 3 months post training. In the 2-day group, the pre-training and post training assessments were completed by 10 participants, where as the 3 month assessment was completed by nine participants [Table 2]. In both the groups, statistically significant difference was seen in overall scores with respect to time (P = 0.008). The mean overall knowledge scores for the 2-day group increased significantly from pre to post test (P = 0.041).
When the knowledge scores for only completers [Table 3] is considered, multilevel analysis revealed a statistically significant difference between the two groups (P = 0.001). The cognitive knowledge scores between the two groups showed a statistically significant difference (P < 0.0001) which could probably be due to a higher difference between the cognitive knowledge scores at the pre-training level itself. When knowledge scores of transmission component is considered, the change in the scores in both the groups over a period of time is not significant.
In terms of actual questions assessed and the number of responders giving a correct reply, the HIV/AIDS transmission scores were higher than cognitive knowledge scores in both the groups. Three items in the cognitive knowledge questions had the least number of correct responders, being "AIDS can damage the brain", "A person can be infected with the AIDS virus and not have the disease AIDS" and "A person who has the AIDS virus can look and feel well". The scores in these questions improved immediately post training, but leveled off at 3 months.
Amongst the participants trained in the 1-day group, seven participants, functioned as trainers and conducted secondary trainings. Amongst the two day group participants, 9 participants conducted secondary trainings. Each participant trained further 10 participants, bringing a total of 160 secondary trainees [Table 4]. These secondary trainees were also homoeopathic and ayurvedic practitioners.
|Table 4: Transfer of training from primary trainees to secondary trainees |
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Socio-demographic characteristics of secondary trainees
The mean age of the secondary trainees trained by of primary trainees of 1-day group was 31.04 years (SD = 6.97, Range = 24-47 years). The number of graduates and post graduates in the respective disciplines were the same. Most of the participants were practicing in clinical settings. The mean age of the secondary trainees trained by of primary trainees of 2-day group was 29.37 years (SD = 7.61, Range = 23-63 years). Most of the participants were continuing their post-graduation studies and were working in the college hospital [Table 5].
HIV/AIDS knowledge secondary trainees
[Table 6] gives the scores of 70 participants, trained by primary trainees of 1-day group.
[Table 7] gives the score of 75 participants trained by primary trainees of 2-day group.
As in the primary trainees, the items "AIDS can damage the brain", "A person can be infected with the AIDS virus and not have the disease AIDS" and "A person who has the AIDS virus can look and feel well" scored low in the secondary trainees. The correct response to the item "AIDS can damage the brain" increased post training, but there was no change in the number of correct responses in the other two items.
The cognitive knowledge scores showed a statistically significant difference before and after trainings in both the groups (P = 0.007 in 1-day group, P = 0.000 in 2-day group). The total scores [Table 8] and transmission knowledge scores were also significantly higher in the trainees of one day participants (P = 0.000 for total score and 0.012 for transmission knowledge score). The total scores and transmission knowledge scores did not however show a statistically significant improvement pre- and post training in the participants of the 2-day group.
|Table 8: Overall knowledge scores of secondary trainees of one - day and two - day group |
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| Discussion|| |
A review of interventions for educating traditional healers about STD and HIV  concluded that training workshop increased the knowledge about HIV/AIDS of traditional healers. With regards to behaviour change, a study conducted in South Africa  detected a significant difference in traditional healers' reports of managing their patients.
The basic training of ayurvedic and homoeopathic physicians in India exposes the practitioners to both the modern concept of the disease as well as the traditional/philosophical concept of disease. The treatment approaches in both the systems focus on the individual constitution or Prakriti, examination of which is important for assessing individual's state of health or disease. Further decision on preventive and curative regimen is based on this.
The participants in this study had lower cognitive knowledge scores than transmission knowledge scores. This training module, although focusing on the modern medicine concept of disease, took into consideration the ayurvedic/homoeopathic approach of the disease as well. This study identified a statistically significant change in the pre-training and post training scores of the participants. However, the change was not statistically significant after 3 months of training. The study conducted in the past  had also shown significant change in knowledge and transmission scores from pre-training to immediately post training, the scores, however increased at 3 months, leveling off at 6 months. In this study, the statistically significant change in scores of secondary trainees implied, that though the primary training was successful and correct messages could be imparted and delivered further, the change has not sustained over a period of time possibly due to the reason that they did not get clients to provide prevention counseling. Therefore, lack of exposure to the topic in daily practice cannot be ruled out.
Although, the training programs have been beneficial for both the primary and secondary participants, to sustain the enhancement in knowledge and practice behaviors, training programs need to be more consistent. Continued medical education trainings (CMEs) would be more beneficial, as compared to single isolated trainings.
Train the training model is frequently used in a number of HIV/AIDS related training programs and target different focus groups. ,, However, few articles have reported its effectiveness as it relates to the percentage of participants who actually go on to conduct trainings.  It has been identified that most of the participants trained in the primary training actually conduct the secondary trainings.
In this training, the one day program was specific to focusing on the disease-based aspect primarily. The 2-day program was more elaborate and focused on the disease-based aspect and on social, ethical and legal aspects of the disease. The participants of 2 day program showed a higher change than the one day group in the primary trainings. For the secondary trainings, the participants were told to focus only on the disease based aspect for both the groups that is the 1 day trainees had to replicate their program as it is. The 2 day trainees had to replicate part of their program and not the total program. The secondary trainings conducted by participants of 1 day program were more effective than those conducted by participants of 2 day program. This implies that secondary trainings are more effective, when the participants are to replicate their programs as it is, rather than when they have to identify some areas and skip the others.
Inclusion of practitioners in public health program would be useful if repeated CMEs are conducted to update with their knowledge. Further, in case of train the trainer approaches, the primary trainings need to be very similar in all aspects to the secondary trainings that the trainees are expected to conduct.
The primary trainings needs to be intensified focusing on both cognitive and transmission knowledge which can then percolate to secondary trainings as well. Specific quality checks needs to be incorporated to assess the quality of secondary trainings.
This study, therefore, identifies a model for inclusion of Ayurveda and Homoeopathy practitioners in the public health program of the country. With more than 5 lakh Ayurveda and homoeopathic practitioners in India,  the potential resource of traditional medicine practitioners can be utilized in the public health programs of the country, especially in the wake of epidemic conditions such as HIV/AIDS. There is a strong need for collaboration between these practitioners and the modern medicine practitioners, so as to manage the HIV epidemic effectively. The combined health care team thus evolved can develop strategies for prevention and treatment of disease effectively.
| Conclusion|| |
The training module on HIV/AIDS was useful in enhancing the knowledge of physicians of Homoeopathy and Ayurveda on cognitive and transmission related aspects of the disease and on its ethical, social and legal implications. With such training programs the homoeopathic and ayurvedic practitioners can play a vital role in prevention of HIV infection by undertaking appropriate patient education and counseling. The training module is available on the website of the CCRH (www.ccrhindia.org)
| Acknowledgement|| |
The authors acknowledge the expertise and technical input of Dr JL Fahey, UCLA and Dr V.P. Singh, CCRH instrumental in development of the training module. The authors also acknowledge the support of Dr K.C. Muraleedharan, Research Officer (H), Dr Bawasker Ramesh, Research Officer (H), Dr Sneha Patki, SRF at RRI Mumbai, CCRH, in organizing the training sessions at Mumbai and in conducting the follow up assessments. The counseling session at Mumbai was undertaken by Ms Poonam Sharma, Tata Institute of Social Sciences, Mumbai. The data entry was done by Ms Nisha, CCRH headquarters. We acknowledge the support of the study participants.
| References|| |
|1.||Nyamathi A, Khurana A, Singh VP, Shrikanth N, Taneja D, Choudhury SM, et al. Delivery of a model HIV prevention and health promotion train-the-trainer program in India by homeopathy and ayurveda practitioners and educators. World Med Health Policy 2010;2:47-72. |
|2.||George S, Nyamathi A, Lowe A, Singh V, Khurana A, Taneja D. Assessing the potential role of indian homeopathic practitioners in HIV education and prevention. World Med Health Policy 2010;2:195-216. |
|3.||Nyamathi A, Singh VP, Lowe A, Khurana A, Taneja D, George S, et al. Knowledge and attitudes about HIV/AIDS among homoeopathic practitioners and educators in India. Evid Based Complement Alternat Med 2008;5:221-5. |
|4.||Leake B, Nyamathi A, Gelberg L. Reliability, validity and composition of a subset of the Centers for Disease Control and Prevention acquired immunodeficiency syndrome knowledge questionnaire in a sample of homeless and impoverished adults. Med Care 1997;35:747-55. |
|5.||Sorsdahl K, Ipser JC, Stein DJ. Interventions for educating traditional healers about STD and HIV medicine. Cochrane Database Syst Rev 2009;7:CD007190. [internet] 2009. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007190.pub2/pdf [Last cited on 2013 Nov 1]. |
|6.||Peltzer K, Mngqundaniso N, Petros G. A controlled study of an HIV/AIDS/STI/TB intervention with traditional healers in KwaZulu-Natal, South Africa. AIDS Behav 2006;10:683-90. |
|7.||Gabel LL, Pearsol JA. The twin epidemics of substance use and HIV: A state-level response using a train-the-trainer model. Fam Pract 1993;10:400-5. |
|8.||Burr CK, Storm DS, Gross E. A faculty trainer model: Increasing knowledge and changing practice to improve perinatal HIV prevention and care. AIDS Patient Care STDs 2006;20:183-92. |
|9.||Bor R, Elford J, Salt H. Evaluation of an intensive 'train-the-trainer' course in AIDS counselling in Zimbabwe. J R Soc Health 1991;111:86-9. |
|10.||Hiner CA, Mandel BG, Weaver MR, Bruce D, McLaughlin R, Anderson J. Effectiveness of a training-of-trainers model in a HIV counseling and testing program in the Caribbean Region. Hum Resour Health 2009;7:11. |
|11.||AYUSH in India 2013; Report [Internet]. New Delhi (IN). Department of AYUSH. Available from: http://indianmedicine.nic.in/writereaddata/linkimages/4859684838-Medical_Manpower%20writeup.pdf [Last updated on 2014 Jan 28, Last cited on 2014 Feb 3]. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]