Customized online and onsite training for rabies-control officers

Abstract Problem It is difficult to deliver adequate training for people working in rabies control in low and middle-income countries. Popular e-learning systems for low-income settings are not well suited to developing and testing practical skills, including laboratory methods. Approach We customized training in rabies control methods for African professionals and students from different disciplines. Trainees participated in preparatory online sessions, evaluations and exercises before and after a 12-day workshop. Trainees and mentors continued to interact through an online forum up to one year after the workshop. Local setting In Africa, 15 000 deaths from rabies occur each year due to a lack of awareness, inaccessibility of post-exposure prophylaxis, inadequate or absent canine rabies-control programmes and lack of governmental financial support. Relevant changes Thirty two trainees – working in health departments, hospitals, veterinary stations and research institutes – were selected to participate; 28 completed the course and passed the final evaluation. Pilot rabies investigation programmes were developed, and two manuscripts submitted for publication. An online forum facilitated further progress for a year after the workshop. Lessons learnt A combination of customized online and onsite training is suitable for teaching disease-control personnel in low-income countries. Participation in this course enabled trainees to advocate for the development of national disease-control strategies. Mentoring is needed to develop a strong network of experts in similar settings.


Problem
In low-and middle-income countries, it can be difficult to deliver adequate training for people working in disease control. Many e-training programmes are based on participatory learning models in which participants share their understanding and monitor their theoretical knowledge through discussion, questioning and interaction with mentors via the internet. The current most popular e-learning systems for resourcepoor settings are massive online open courses 1,2 which have been used by tens of thousands of students around the globe. 3 However, this format is not well suited for specific practical training needs.
Scientists and public-health professionals working in neighbouring countries often miss opportunities to exchange information because collaborations have been traditionally formed between distant, high-income countries. Public health managers and scientists are often trained separately, making it difficult to link human and animal health at national and international levels.
Our aim was to provide practical training on rabies prevention in Africa for students and professionals in animal and human public health sectors. 4,5 We also wanted to address critical gaps in rabies control as have been described elsewhere. [6][7][8] Approach We used an approach called customized online training, (COLT) which focuses on small sets of trainees and is designed for situations where acquisition of skills and direct training by experts are needed. With this approach, it is feasible to tailor training to each individual trainee in a way that would be impractical in a system designed for mass audiences. The COLT approach has been used successfully for several workshops and courses in Africa, Asia and South America (http://octave.bio-med.ch). We describe here the use of the COLT approach in a course on the control and surveillance of rabies organized in Dakar, Senegal, in December 2013.

Local setting
Rabies is a lethal encephalitis due to a lyssavirus mainly transmitted to humans by the bite or scratches of infected animals. Approximately 15 000 deaths from rabies occur in Africa each year due to a lack of awareness about the disease and the consequences of dog bites, lack of access to post-exposure prophylaxis, and inadequate or absent canine rabies-control programmes.
Online and onsite rabies-control training, Africa Hervé Bourhy et al.
ogy and/or epidemiology. Participants needed to be fluent in French and have at least a bachelor degree and preferably a master's degree. The course was advertised through a website and by participating international organizations and regional networks. Most of the 106 applicants were from Francophone African countries. Trainees were selected on the basis of a curriculum vitae, letter of motivation and three letters of recommendation. Thirty-two participants working in national and regional veterinary stations, hospitals or research institutes in 13 countries (Algeria, Burkina Faso, Cameroon, Chad, Congo, Côte d'Ivoire, Democratic Republic of the Congo, Madagascar, Mali, Niger, Senegal, South Africa, Togo) were selected and encouraged to start pre-workshop activities.

Online pre-workshop activities
An online pre-training assessment tool was sent to participants, who completed this before starting a set of three activities. First, trainees were provided with annotated articles on rabies and asked to respond to questions on epidemiology, pathogenesis, laboratory methods of diagnosis, statistics and clinical features of infection. Modules could be downloaded to allow the trainees to study despite irregular internet access. Second, as a virtual team exercise, trainees were asked to write a national plan for the control and surveillance of rabies in Senegal. The trainees had to interact with each other using an online forum and address specific questions that were provided by the experts. Third, trainees had to write a manuscript on their research related to rabies, guided by an application developed by Jonathan Fuchs (Department of Public Health, San Francisco, United States of America). These activities required about 70 hours of individual work, followed by a second online evaluation.

Workshop activities
The onsite workshop, over 12 days, focused on practical sessions including: testing rabid dog-brain samples by immunofluorescence or by reverse transcriptase polymerase chain reaction (RT-PCR); anti-rabies antibody detection; analysing ribonucleic acid (RNA) sequences; and, estimating the growth rate of epidemics. The 24 teachers came from seven countries: Cambodia (1), France (4), Italy (1), Senegal (12), South Africa (1), Switzerland (3) and the United Kingdom of Great Britain and Northern Ireland (2). The organization of the workshop activities favoured debates, discussions and analysis of local contingencies to find practical, economical and reliable solutions to the current rabies situation in Senegal. Work done during the preworkshop period was finished during the workshop and presented to the panel of experts. The experts made recommendations and forwarded the proposed national plan, including a budget, to the ministries in charge of rabies control and surveillance in Senegal.
To assess the effectiveness of the workshop process, we held a final examination. Twenty-eight trainees succeeded with scores above 74% (range: 74-88%). The trainees attending the whole course received five credits from the European credit transfer and accumulation system, delivered by Lausanne University, Switzerland. The completion rate of the course (86%; 28/32) was higher than for many massive open online courses, which often have completion rates below 20%. 9 All trainees completed a final evaluation in which they provided feedback on the course and indicated how they planned to transfer the knowledge and skills they had acquired to their daily practice.

Post-workshop activities
During the year following the course, discussions on the online forum continued between the participants and the teachers. Pilot rabies investigation programmes were developed by the participants and sent to the experts for review and then submitted to national or international funding agencies. The participants organized other courses on rabies control and prevention. These were held at the local or provincial level and in Côte d'Ivoire, Madagascar and South Africa, at the national level. Eight manuscripts on rabies-related topics were written and two have been accepted for publication in international peer-reviewed journals.
These outcomes illustrate the intensity of the post-workshop activities, the need for an ongoing training component and the value of mentoring provided before, during and after the workshop. Mentoring is a core component of medical education and career success and should be promoted in low-and middle-income countries. 10 Box 1 summarizes the main lessons learnt during this workshop.

Costs and human resources
The budget for this course was 3000 Euros per trainee. This covered creating and maintaining the website, managing the online forum, travel to Senegal and local expenses for trainees and experts. The participants paid no registration fees. Of the 24 teachers present during the workshop, 14 were experts working on rabies in ministries and research institutions in Senegal. This mix of foreign and local teachers helped to ensure the support of the host country and meant that debates between participants were informed by a very good understanding of the local situation in the field. ■

Box 1. Summary of main lessons learnt
• Customized online training is suitable for disease-control programmes in low-income countries. • Online pre-workshop activities are essential for preparing participants for the workshop. • Mentoring is needed to create a strong network of disease-control experts working in similar settings.

Formación en línea y presencial personalizada para los encargados del control de la rabia
Situación Es difícil proporcionar una formación adecuada a aquellos que trabajan en el control de la rabia en países de ingresos bajos y medios. Los populares sistemas de aprendizaje en línea en comunidades de ingresos bajos no son adecuados para desarrollar y poner a prueba las habilidades prácticas, incluidos los métodos de laboratorio. Enfoque Se personalizó la formación en los métodos de control de la rabia para los profesionales y estudiantes africanos de diferentes disciplinas. Los alumnos participaron en sesiones preparatorias, evaluaciones y ejercicios en línea antes y después de un taller de 12 días. Los alumnos y los profesores siguieron interactuando a través de un foro en línea hasta un año después del taller. Marco regional En África, hay 15.000 muertes de rabia cada año debidas a la falta de concienciación, la inaccesibilidad de la profilaxis postexposición, los programas inadecuados o ausentes de control de la rabia canina y la falta de apoyo financiero del gobierno.