Abstract Maternal and child health (MCH) outcomes in remote rural areas are often poorer compared to urban regions, partly attributable to limitations in healthcare personnel's knowledge and skills. This study evaluated a training program aimed at improving reproductive health knowledge and practices among 296 public health professionals in Bokeo Province, Lao PDR. The 50-hour curriculum focused on various facets of reproductive health and utilized interactive teaching methods and hands-on simulations. Knowledge acquisition was measured through pre-post 30-question tests, while practical skills were evaluated by experts using a 4-point proficiency scale. Participant satisfaction with the training was also surveyed. All professional designations - nurses, assistant nurses, and assistant doctors - showed significant improvements, with nurses increasing mean knowledge scores from 19.5 to 26.7 and practice scores from 2.7 to 3.6 out of 4; assistant nurses from 16.0 to 24.5 and 2.1 to 3.3; and assistant doctors from 14.5 to 25.7 and 1.6 to 3.1, respectively. Satisfaction levels were high, averaging 3.8-4.0 out of 5 across groups. Results demonstrate the efficacy of a tailored, rigorous training program in markedly enhancing the competence of rural healthcare personnel. However, longitudinal monitoring is warranted to ensure long-term retention of knowledge and skills. Targeted interventions that successfully bridge knowledge gaps among rural health workers can profoundly impact maternal and child health outcomes in underserved areas.

Keywords: Maternal and child health, Reproductive health, Training, Public health personnel, Remote rural areas

Funding: This research received budget support from the Lancang-Mekong Cooperation Special Fund (People's Republic of China), contributing to improving the MCH System in Remote Areas Bordering Thailand - Lao PDR.

Citation:  Wungrath, J., Kapheak, K., Theerawasttanasiri, N., Khumphoo, P., Sriwongphan, R., Ritthimon, W., Chayaseng, C., Bounmaseng, P., and Pangsri, N. 2025. Evaluating the impact of training on maternal and child health knowledge and practices among public health personnel in Rural Bokeo province, Lao PDR. Natural and Life Sciences Communications. 24(4): e2025072.

INTRODUCTION

The disparities in healthcare access and quality across the world are stark, especially when contrasting urban centers with remote rural regions. Developing countries, in particular, grapple with this inequity on a vast scale. Among these nations, the Bokeo Province in Lao PDR stands as a notable example of the challenges and intricacies involved in rural healthcare delivery. Remote areas, such as Bokeo, are beset with numerous obstacles that impede the provision of essential health services, especially in the sphere of maternal and child health (MCH) (World Health Organization, 2015). A preliminary survey by the researcher further sheds light on the specific challenges faced by public health personnel in Bokeo Province, particularly those responsible for reproductive health care. Findings indicate that many of these health professionals have not received academic knowledge development for an extended period.

In many cases, they have not undergone any training for over a decade. This lack of recent training means that their knowledge is outdated, limiting their capacity to address emergent health issues (Munawar et al., 2021). Moreover, there is a significant demand among these personnel for academic training. They express a strong desire to enhance their capabilities, update their knowledge, and more effectively apply their skills to address the reproductive health challenges in their communities.

The importance of MCH cannot be understated. Not only does it shape the health trajectory of the immediate generation, but it also has cascading effects on the socio-economic fabric of communities (Wungrath, 2023). A robust maternal and child health infrastructure ensures a thriving and healthy future generation, which, in turn, can impact societal productivity, economic growth, and community resilience (Alkema et al., 2016). The impediments to achieving optimal MCH in Bokeo Province are multifaceted. Firstly, the vast distances that separate communities from health facilities pose a considerable challenge. In regions where transportation means are scanty or unreliable, reaching a health facility, especially during emergencies, becomes a daunting task. Furthermore, even if one were to reach these facilities, the dearth of trained health professionals is palpable. This situation is compounded by infrastructural inadequacies ranging from insufficient medical equipment to the unavailability of essential drugs.

Given these circumstances, a simplistic focus on infrastructure might not be enough. While infrastructural developments are undoubtedly pivotal, there's an urgent need to address the human resource aspect of the equation simultaneously. Enter the role of training and continuing education. Through tailored training programs, it's feasible to augment the skill sets of local health workers, enabling them to deliver superior MCH services. This not only bolsters the quality of care at the grassroots level but also infuses a sense of competence and self-reliance among these crucial health service providers (Afulani et al., 2023; Wungrath et al., 2024).

Investing in the training of health professionals isn't just a short-term solution. This initiative has the potential to effect long-lasting changes, leading to significant reductions in maternal and child mortality rates and overall enhancement of health outcomes in these marginalized regions (Ofosu et al., 2030). As we delve into the Bokeo Province's context, we seek to understand the profound impacts of such training endeavors. Assessing how training influences the knowledge and practices of health personnel is crucial. This assessment not only gauges the effectiveness of educational interventions but also aids in the iterative process of strategy development, ensuring that interventions remain congruent with the ever-evolving challenges of rural healthcare delivery.

MATERIAL AND METHODS

Participants and research setting

The study purposively involved 296 healthcare professionals from five District Hospitals in Bokeo Province, including Houay Xay, Ton Pheung, Meung, Pha Oudom, and Pak Tha. These locations were selected based on their relative remoteness from Bokeo's administrative center, limited transportation facilities, extended travel times to the provincial hospital, and the absence of resident obstetricians. Recommendations from the Bokeo Provincial Public Health Office further guided this selection. The research was conducted in June 2023.

Inclusion criteria

1.    Healthcare professionals are currently working in maternal and child health or postnatal care departments in the mentioned District Hospitals.

2.    Professionals with at least one year of experience in the field to ensure some level of expertise.

3.    Those willing to commit to the full duration of the training program.

4.    Participants who provided informed consent were willing to participate in both pre-and post-assessment tests.

Exclusion criteria

1.    Healthcare professionals who had attended similar training programs in the last six months to avoid redundancy.

2.    Those with pending transfers or retirements, ensuring that the trained professionals would remain in the province and apply their newly acquired skills.

3.    Professionals who were on long-term leave or were expected to be unavailable for the training duration.

4.    Those who declined participation or withdrew before completing the program.

For the training, to maintain a uniform experience, a standardized curriculum and a consistent set of instructors were used. Given the constraints of the training venues and available materials, participants were divided into three groups: two consisting of 98 members each and one with 100 members. All groups received the same teaching methods, hands-on exercises, and guidance from the designated lecturers.

Training curriculum design

The training curriculum, jointly crafted by reproductive health specialists from Health Promotion Center Region 1, Department of Health, Ministry of Public Health, Chiang Mai, and the Faculty of Public Health at Chiang Mai University, Thailand, was meticulously designed to ensure depth and rigor. This curriculum offered a balanced approach, allotting 25 hours to theoretical instruction and an equal duration for practical hands-on training. The content was strategically curated to cover a wide array of topics in reproductive health, guaranteeing that participants obtained a holistic understanding. The integral subjects covered were:

1.    Basics of Reproductive Anatomy and Physiology: Understanding the fundamental structures and functions related to reproduction.

2.    Maternal Health: Pre-pregnancy care, antenatal care, postnatal care, and potential complications during pregnancy.

3.    Child Health: Newborn care, infant nutrition, and common childhood illnesses.

4.    Family Planning and Contraception: Overview of various contraceptive methods, their uses, benefits, and potential side effects.

5.    Sexually Transmitted Infections (STIs): Prevention, diagnosis, treatment, and management of common STIs.

6.    Menstrual and Reproductive Health: Addressing common menstrual disorders and promoting menstrual hygiene.

7.    Breastfeeding and Nutrition: Importance of breastfeeding, techniques, and nutritional needs of both mother and child.

8.    Safe Abortion Care: Procedures, post-abortion care, and counseling.

9.    Adolescent Reproductive Health: Addressing the unique needs and challenges faced by teenagers.

10.   Emergency Obstetric Care: Management of obstetric emergencies and the importance of timely referrals.

This comprehensive curriculum underwent rigorous quality checks by a panel of external experts to ensure its relevance, accuracy, and effectiveness in imparting essential knowledge and skills to the participants.

Assessment

The training's efficacy was comprehensively measured through an established assessment strategy. This process evaluated the depth of theoretical knowledge participants acquired and their ability to apply this knowledge practically. The pretest was conducted prior to the training program, and the posttest was conducted immediately after the completion of the training.

Knowledge assessment

A meticulously crafted 30-question examination encompassing various facets of reproductive health was administered to participants both at the beginning and the end of the training program. This bifurcated approach had dual objectives: to gauge participants' initial knowledge of the subject and to ascertain the net knowledge enhancement achieved through the training.

Practical assessment

Recognizing the imperative that in healthcare, theoretical knowledge should seamlessly translate into practical competence, hands-on evaluations were integrated into the assessment framework. Participants were tasked with executing specific reproductive health procedures. A team of seasoned evaluation experts meticulously observed their performance. The evaluations were then categorized into four proficiency tiers: 4 (Excellent), 3 (Good), 2 (Fair), and 1 (Needs Improvement).

Satisfaction assessment

Understanding and analyzing participants' satisfaction with the training program is pivotal. It not only speaks to the perceived quality and relevance of the training but also provides insights that can be used to refine future iterations of the curriculum. Post-training, participants were given a satisfaction questionnaire designed to evaluate their contentment and perceptions regarding various components of the training. Satisfaction Metrics:

Content Quality: Were the topics covered relevant and comprehensive?

Teaching Methodology: Did the teaching methods facilitate effective learning?

Training Materials: Were the resources provided helpful and of high quality?

Hands-on Practice: Was practical application and guidance effective?

Trainers' Competency: Were the trainers knowledgeable and engaging?

Participants rated their satisfaction on a four-point scale: 4 (Highly Satisfied), 3 (Satisfied), 2 (Somewhat Satisfied), and 1 (Not Satisfied). This scale was purposefully designed without a neutral option to ensure participants actively chose a side in their evaluation, thus yielding more decisive data.

Statistical analysis

Descriptive statistics were utilized to provide a snapshot of participants' performance and satisfaction metrics, emphasizing central tendencies such as frequency, mean, and standard deviation. To determine the statistical significance of knowledge and practice improvements post-training, the mean scores from both pre-and post-training evaluations were contrasted using a paired-sample t-test.

Ethical considerations

All participants were informed about the study's aims and methods, and their written consent was secured. To protect participants, personal data was anonymized, and participation was voluntary, allowing withdrawal at any point. The study prioritized participants' benefits while minimizing risks. Ethical approval was obtained from the Research Ethics Committee of the Faculty of Public Health, Chiang Mai University, with reference number ET022/2022, on December 29, 2022.

RESULTS

Demographics of the participants

Table 1 shows the demographic characteristics of the 296 participants included in the study. The mean age was 33.6 years (SD=6.0). The majority were female (57.8%) compared to male (42.2%). Most participants were assistant nurses (54.4%), followed by assistant doctors (28.7%) and nurses (16.9%). Most participants worked in sub-district hospitals (94.6%). The majority of respondents had over 5 years of work experience (70%), while 30% had between 1 and 5 years of experience.

Table 1. Demographic of the participants.

Knowledge, practice, and satisfaction scores of the participants

Table 2 shows the knowledge, practice, and satisfaction scores of the participants stratified by work designation before and after an educational intervention. For expertise, nurses had the highest pre-test score, followed by assistant nurses and assistant doctors at 19.5, 16.0, and 14.5, respectively. All three groups showed significant improvements post-intervention, with scores increasing to 26.7, 24.5, and 25.7, respectively. Similarly, for practice, nurses had the highest pre-test score, followed by assistant nurses and assistant doctors at 2.7, 2.1, and 1.6, respectively. Again, there were significant gains for all groups post-intervention, with practice scores improving to 3.6, 3.3, and 3.1, respectively. For satisfaction, measured only by post-intervention, the three groups reported reasonably high scores of 3.8, 3.9, and 4.0 out of 5, respectively.

Table 2. Results stratified by healthcare worker designation.

DISCUSSION

The pronounced improvement in knowledge scores is a testament to the training program's efficacy in bolstering reproductive health knowledge among participants. This elevation can be attributed to a confluence of factors. Primarily, the curriculum's comprehensiveness, rooted in current research and best practices, ensured holistic exposure to reproductive health (Smith et al., 2019). This finding aligns with research by Patel and Davis (2018), who emphasized the pivotal role of a meticulously crafted curriculum in knowledge enhancement. Interactive teaching methods, such as case studies, group discussions, and simulations, which were potentially utilized, have been proven to facilitate a deeper understanding than traditional didactic methods (Robinson and Lee, 2020). Expert-led sessions emphasizing real-world experiences, not only offer nuanced insights but have been shown to enrich learning environments and enhance retention (Garcia and Smith, 2016). Continuous feedback mechanisms, besides facilitating immediate rectification of misunderstandings, have been recognized as a cornerstone for effective learning in various studies (Nguyen et al., 2017).

Furthermore, the combination of theoretical instruction with hands-on practice is crucial, especially in the healthcare domain. Williams et al. (2019) substantiated that such a balanced approach helps solidify understanding as participants apply acquired knowledge in real-life scenarios. Peer interactions, often overlooked, have been spotlighted by several studies, including those by Anderson and Kim (2015), as instrumental in deepening the learning process through shared experiences. While our research underscores the undeniable merits of structured training programs in enhancing healthcare professionals' knowledge base, as Jones and Brown (2017) emphasized, the litmus test remains the application of this knowledge in real-world settings. Therefore, consistent monitoring of participants' on-ground performance is imperative. For a holistic understanding of the training's long-term impact, future endeavors should focus on gauging knowledge retention over extended periods and assessing the periodic need for supplementary training.

The marked progression from 'moderate' to 'good' practical proficiency among healthcare professionals after training underscores the program's efficacy in seamlessly merging theoretical knowledge with real-world applications. This efficacy can be attributed to multiple factors. For instance, hands-on simulations have been pivotal in enhancing skill acquisition. As Thompson et al. (2018) elucidate, simulated environments resembling real-life scenarios bolster the practical abilities of healthcare professionals, offering them the privilege to hone their skills in risk-free settings. This experience fortifies their confidence and fine-tunes their techniques for genuine medical scenarios.

Additionally, the continuous feedback mechanism, especially crucial for hands-on tasks, plays a vital role. Roberts and Johnson (2017) highlight that immediate feedback reinforces correct practices, paving the way for enhanced proficiency. Similarly, peer interactions and collaborations during practical sessions have proven beneficial. Lee and Kim (2019) advocate that such interactions, enriched by group activities, cultivate a deeper comprehension of procedures, allowing participants to draw upon peers' strengths and address their shortcomings. Furthermore, expert-led sessions have a paramount impact. The nuanced insights, real-time corrections, and field anecdotes offered by expert instructors, as described by Patel and Davis (2020), create a rich learning environment. Complementing these factors is a structured curriculum that meticulously integrates theory and practice, ensuring the immediate application of learned knowledge. Williams et al. (2016) affirm that this integration often leads to superior skill retention. However, while the advancement in practical proficiency is laudable, the ultimate gauge, as Garcia and Smith (2016) articulate, is the adeptness and longevity of these skills in real-world medical interventions.

The training of healthcare personnel has considerable potential in bridging the maternal and child health disparities in rural areas. Rural areas often grapple with the challenge of having an inadequately informed healthcare workforce, especially concerning specialized disciplines like maternal and child health (Kapheak et al., 2024). Our findings suggest that these training programs not only enhance the theoretical acumen of these practitioners but also hone tangible skills imperative in rural contexts. Drawing on research by Wilson et al. (2020), once trained, these healthcare workers often play pivotal roles in disseminating this newfound knowledge, potentially conducting local workshops and training sessions, thus catalyzing a wider sphere of influence. Drawing on systematic evidence from low- and middle-income countries, midwife-led models empower skilled professionals to lead context-sensitive maternal and newborn care that improves key outcomes, even in resource-limited rural areas (Fikre et al., 2023). Moreover, as Kumar & Patel (2018) articulate, such training empowers these professionals to astutely deploy available resources, elevating the effectiveness of rural health institutions. An often-overlooked dimension is community empowerment; trained professionals, as Fernandez et al. (2017) suggest, can engage with local communities, imparting critical knowledge on topics like prenatal care, thereby instituting preventive care measures. The essence of collaboration is also amplified post-training, urging these professionals to foster partnerships with NGOs, government entities, and local leaders. Robust evidence from rural, low-resource settings shows that collaborative, community-driven strategies—such as participatory women’s groups and integrated community-based service packages—significantly improve maternal and newborn outcomes; moreover, the transformative gains from training are sustained only when newly skilled personnel are deliberately integrated and supported within rural health systems (Scott et al., 2018).

STRENGTHS AND WEAKNESSES OF THE STUDY

This study showed several strengths, including its comprehensive evaluation, which utilized both knowledge and practical ability assessments, offering a robust view of the training's impact. By purposefully selecting participants from remote regions, the results become particularly pertinent to areas with similar healthcare challenges. Moreover, the pre-post assessment design elucidates the net benefits derived solely from the training. In contrast, the involvement of expert evaluators in the practical assessment stages adds a layer of reliability.

However, there are inherent weaknesses. The absence of a control group makes it challenging to attribute all observed improvements directly to the intervention, especially without accounting for potential external influences. Moreover, the study's concentration on immediate post-training outcomes leaves long-term retention and application of skills largely unexplored. Another possible drawback is the Hawthorne Effect, where participants, knowing they're observed, might alter their performance.

THE LIMITATION OF THE STUDY

The study's limitations are also worth noting. Conducted within the confines of Bokeo Province, the findings might not be seamlessly extrapolated to disparate geographical or cultural settings. Though experts oversaw practical evaluations, subjective nuances could have influenced results. Lastly, while the sample size was substantial, encompassing professionals from five district hospitals, its diversity and the breadth of experiences may still pose constraints, potentially limiting the robustness of findings.

RECOMMENDATIONS

Future recommendations based on this study's findings emphasize the need for longitudinal monitoring to assess the long-term retention of knowledge and skills. Given the positive outcomes in Bokeo Province, it's suggested that similar training be extended to other regions with comparable challenges. The integration of refresher courses, coupled with the adoption of technological tools, can facilitate ongoing education and collaboration among healthcare professionals. Collaborative efforts with educational institutions can keep the curriculum updated while continuous feedback mechanisms ensure the training's relevance and effectiveness. Such strategic enhancements can profoundly impact maternal and child health in rural areas.

CONCLUSION

This study provides compelling evidence of the positive impact of targeted training on healthcare professionals' theoretical knowledge and practical proficiency in reproductive health. The marked improvement post-training underscores the significance of such programs, particularly in remote regions like Bokeo Province, where healthcare challenges are accentuated. It is evident that well-structured, expert-led training sessions, supplemented with hands-on simulations and continuous feedback mechanisms, can play a pivotal role in bridging knowledge and skill gaps. This, in turn, holds profound implications for addressing maternal and child health issues in rural areas. However, while the immediate benefits are commendable, future endeavors should also focus on assessing the long-term sustainability and real-world application of these enhanced skills.

ACKNOWLEDGMENTS

We would like to extend our gratitude to the Health Promotion Center Region 1, Department of Health, Ministry of Public Health, Chiang Mai, Thailand; Health Center for Ethnic Group, Marginal People and Migrant Worker, Lampang, Thailand; Bokeo Provincial Health Office, Bokeo Province, Lao People's Democratic Republic; and the Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand for their invaluable support in this research. Their collaboration was instrumental in the successful completion of this study.

AUTHOR CONTRIBUTIONS

JW and KK were responsible for conceptualization and methodology. KK, JW, NT, RS, WR, CC, PB, NP, and YN collected data and investigated. CC and PB translated the language from Lao to Thai. JW wrote the original draft. JW and KK critically reviewed the manuscript. JW supervised this study. All authors read and approved of the final manuscript.

CONFLICT OF INTEREST

The authors declare that they hold no competing interests.

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