One hundred and eighty-four medical personnel (91 doctors and 93 staff nurses) from 82 medical institutions were trained which led to the immediate establishment of lymphoedema clinics at all these institutions to provide the EPC for these patients (Tables 1, 2). Interviews with all the participants in all the six different sessions found that they were very enthusiastic about the training sessions and the included activities; participants were especially satisfied with the development, as part of the training program, of quality institutional proposals for starting and carrying out MMDP services for their own patients suffering from LF.
Feed back on the effectiveness of sessions
The structured questionnaire asked of the 144 attendees included questions related to the instructors/facilitators, to the organisation, and as well the opportunity to suggest changes/improvements in the format of the training. Comments about the instructors were all positive and no negative comments were made; those regarding the organisation were almost exclusively positive with an only a few minor comments related to logistic issues (e.g., “dinner should be provided”); a range of useful comments were made regarding improving the training session (e.g., providing certificates, involving the participants more actively, better infrastructural facilities). In summary, the vast majority of comments responding to the post-training interviews underscored the positive nature of the training sessions.
Development of proposals for starting lymphedema clinics
A key component of the training sessions was the development of specific proposal for training and patient care in the respective home bases of the participants. These proposals included appraising their superintendents and district medical officers (DMOs) about the need for initiating the MMDP services, the training of the other health care providers in their own hospitals, carrying out infrastructure modifications, procuring the necessary materials for management of lymphedema and acute attacks, i.e., antibiotics and other drugs, antiseptic, anti-fungal ointments, and the acquisition of the necessary materials for limb hygiene measures. These plans also included introduction of appropriate information, education and communication (IEC) activities and maintenance of records and documents, as well planning for regular documentation and reporting on their ongoing activities.
Support from State Government medical administration
An important factor in the success of these training sessions was the support from the State Health Administration. A policy decision was taken by the government that Kerala state should achieve LF elimination and MMDP in addition to MDA, was to be a key component of that strategy. To provide this in all parts of the State a team of health care providers—a doctor and staff nurse—from each Taluk Head Quarters hospitals should be given training in LF MMDP. These teams would then train others in their respective facilities, and thus ensure a wide distribution of the needed services across the state. The second example of important administrative support for the training activities was the attendance of high-level government officials at the opening of each session. This underscored the importance placed by the State Government in these training sessions.
Assessment of learning
A comparison of the pre-training tests with the post training ones was completed, showed a very high degree of learning achieved by virtually all attendees. Figure 3 shows the pre-training and post-training scores obtained by the attendees at each session who completed both the tests. Before training the number of questions answered correctly across the six sessions ranged from an average of 9.4 (with a range between groups of 8.6–10.6 of the 20 questions answered correctly; after training this improved to 16.7 (16.1–20.0). Thus, across all the training sessions there was almost twice as many questions being answered correctly after training, and in each group, there were attendees who got all questions correct or only answered one or two questions incorrectly. The institutional planning projects were all examined and found to be of high quality and to contain all the major needed components for implementation.
Post training activities
On returning to their posts after the training session, the participants had discussions with their superintendents and DMOs, organized training program for doctors, nurses and health care workers and carried out various IEC activities. Importantly the State Government allocated funds for the LF MMDP activities in every district as part of the SDG program and now all the districts with clinical LF have started MMDP clinics. Twelve months after the training sessions were completed a total of 82 MMDP clinics which had been started in the state as part of the overall SDG program with an average of 5 facilities per district.
Increases in patients receiving care
The training of the medical staff occurred through organized structured sessions over 6 months that included information, hands-on demonstrations and the development of specific LF lymphoedema care plans for the trainees’ home hospitals and medical centers (Fig. 1).
In the following 6 months following the training the number of previously unidentified lymphoedema patients registered and receiving care at these clinics ranged from 296 to almost 400 per clinic, with a total of 3,477 new patients receiving the EPC during this period.