A contextual model for continuing professional development (CPD) to build capacity in low-resource countries: Rwanda

Abstract

Background Continuing professional development (CPD) is an important component of capacity building in low-resource countries. The published descriptions of rehabilitation CPD models are limited. Physiotherapy in Rwanda is a relatively young profession with established degree-level training that was initiated in 1997, three years after the Rwandan genocide. In 2013, a law was enacted requiring CPD for licensure as a physiotherapist. This law, the background of a country recovering from a recent history of war and the established university entrylevel training, set the stage for a project to support professional development. Health Volunteers Overseas, a non-profit organisation, obtained funding from the United States Agency for International Development to work in partnership with the Rwandan Physiotherapy Association and University of Rwanda to advance the profession. The goals of the Advancement of Rwandan Rehabilitation Services Project courses which were offered from March 2013 to May 2015 were as follows: (a) to enhance knowledge, skills and abilities of physiotherapists to provide optimal care and upgrade standards and (b) to reach out to medical providers and community stakeholders to promote referrals and expand access to rehabilitation. Purpose To describe a contextual CPD model used to design, develop and implement a series of courses to enhance the knowledge, skills and abilities of physiotherapists in Rwanda. Methods A descriptive educational case study approach is used to illustrate the four phases of the project: a. needs assessment, b. funding acquisition and planning, c. organisation and instructional design, d. delivery and evaluation. The needs assessment used previous organisational experience from projects in other countries and author experience within the physiotherapy higher education system in country. After the grant was awarded, onsite focus groups and interviews with key stakeholders were completed during the initial portion of the grant. Instructor recruitment in both the United States and Rwanda along with course planning was also conducted in the first phase. Facilitating factors such as the established university-level physiotherapy training, a WCPT recognised association, a core group of strong academic and clinical physiotherapists and recent CPD regulations facilitated post-graduate initiatives. The geographic barriers for individuals with disabilities to access care and the need to assist physiotherapists to develop skills regardless of their location led to the decision to offer five regional courses. Courses were offered in both rural and urban areas over 3-5 weekends for 2-3 cohorts per course. The grant supported travel costs for the course participants. Since physiotherapy was in a phase of early development, there was limited awareness of the benefits of physiotherapy throughout the country. This was addressed through project goals to disseminate and apply information in each local setting. Active learning approaches such as projects, discussion of cases seen in the clinic and introducing outcome assessment were used to help expand awareness. Participants were also encouraged to offer presentations for other professionals and patient populations in their home communities. Five progressive courses included practical evaluation and management topics identified by Rwandan stakeholders for patients with spinal and extremity musculoskeletal diagnoses, neurological diagnoses, paediatric patients and respiratory system diagnoses. The International Classification of Functioning model was used as a foundation for all courses. A final leadership symposium was also offered to attendees who were identified as potential leaders of the profession in Rwanda. Four threads were reinforced across all courses regardless of content focus - clinical decision-making, active treatment techniques, clinical skill building and using functional outcomes. Content experts from the United States partnered with Rwandan co-instructors to provide instruction and met during the week to plan and debrief after each weekend course. Instructors also provided onsite mentoring during local clinic site visits with attendees. This component of the project was an important element to reinforce learning, provide local examples for instructors and also served to increase visibility of the profession. Clinical observations and a post-course survey were used to reflect on and evaluate educational outcomes. Results Of the 254 physiotherapists registered with the Rwandan Allied Health Council in 2015, 168 (66%) attended courses. Participants completed more than one course with an average of 3 weekend courses attended. Courses were held in Kigali, the capital of Rwanda, as well as Butare, a location with more rural access. The distribution of courses met the needs of multiple regions with 48% of participants coming from rural areas. Instructors also completed 302 clinical site visits. Participants reported improvements in their skills and overall quality of care for individuals with disabilities. During clinical site visit observation, the majority of participants accurately identified functional problems and impairments and determined whether referral was needed, performed treatment safely and provided home exercises. Selecting and modifying treatments required some assistance from instructors, while documentation and outcome measures required the most assistance. Conclusions Critical elements of the model for CPD delivery employed in this programme were offering the courses in rural and urban areas, course continuity, co-instructors, active learning activities, practical focus and clinical mentoring. Choices were informed by contextual factors, gathered from previous experience and the onsite needs assessment. Strengths included involvement of in-country leaders and instructors, participation by the majority of Rwandan physiotherapists and multiple courses with consistent themes. Implications This model for rehabilitation development may be applicable in countries with established university systems but without an established CPD system. Contextual factors gathered from previous experience and an onsite needs assessment process can be used to inform choices during planning. Mandatory CPD requirements encouraged participants to prioritise and value the courses offered. Useful methods to enhance rehabilitation in low-resource countries include workshops focussing on practical skills, emphasis on application of clinical reasoning and clinical mentoring for transfer of training. Multiple progressive courses enhance development of higher-level clinical skills and professional communities of practice. Useful elements for facilitating transfer in the community were mentoring in the workplace, incorporating explicit goals for advocacy and the co-instructor model.