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Effectiveness of a training-of-trainers model in a HIV counseling and testing programme in the Caribbean region
Global Health Sciences Literature Digest
Published August 17, 2009
Journal Article

Hiner CA, Mandel BG, Weaver M, Bruce D, McLaughlin R, Anderson J. Effectiveness of a training-of-trainers model in a HIV counseling and testing programme in the Caribbean region. Hum Res Health 2009 Feb17;7:11.


To evaluate the effectiveness and sustainability of a voluntary counseling and testing (VCT) training program based on a training-of-trainers (TOT) model in the Caribbean Region

Study Design

Information from the Training Information Monitoring System (TIMS), a database that tracks training efforts, was used to generate reports on the number of people trained in clinical skills (CS), clinical training skills (CTS) and advanced training skills, as well as the number of trainings each clinical trainer and advanced trainer had conducted since their original training. Next, drawing on contact information stored in TIMS, the program team conducted a telephone survey in mid-2005 to follow-up course participants. Interviewers also called sites where participants worked at the time of the CS course.


13 countries within the Caribbean Region, including Anguilla, Antigua and Barbuda, Barbados, the Bahamas, Dominica, Grenada, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Surinam, Trinidad and Tobago, and Turks and Caicos.


Between June 2002 and May 2005, 2,432 people in the Caribbean Region attended a CS course and 167 attended a CTS course. The selection of participants for CS courses in each country was based on specific criteria, such as having existing responsibilities related to HIV service delivery and demonstrating interest and professional initiative in this program area. Each country's ministry of health or national AIDS program was responsible for identifying individuals who met the criteria for VCT trainings. For the selection of participants to attend the CTS course to become trainers, the method varied by country.


The TOT model incorporated a combination of competency-based and mastery learning methods applied through a defined "trainer pathway," in which a provider is ultimately able not only to train peers, but to design and develop curricula for training programs. The training employed competency-based learning, a learning-by-doing training approach that focuses more on correct performance-demonstrating the knowledge, skills, and attitudes needed to perform a clinical service according to defined standards-han on simple acquisition of knowledge. The trainer pathway is a four-step process that assists clinicians in making the transition from health care provider to clinical trainer, then to advanced trainer and, finally, to master trainer.

Primary Outcomes

The percentage of participants trained as VCT providers who were providing VCT services, and the percentage trained as VCT trainers who subsequently conducted VCT skills courses


Data were available for 1,660 of the trainees. Interviews took place from 6 months to 3 years after initial training.

The percentage of participants trained as VCT providers who were providing VCT services: Among the 1,660 CS course participants represented in the survey, 1,125 (68%) were currently providing VCT services. There were 448 trainees (27%) who were not working at their original sites, but information obtained confirmed that 56 (12.5%) of them were providing VCT services elsewhere. For most that were no longer at the original site, it was not known whether they were providing VCT services and it was assumed that they were not. Of the 1,069 people who were providing VCT services at the original site, information on their current role was available for 1,048. Of these, 560 (53%) provided these services as their primary role and the remainder as their secondary role.

The percentage trained as VCT trainers who subsequently conducted VCT skills courses: Of 167 trainees who completed the CTS course, 134 (80%) became certified trainers. The percentage of trainers who were certified varied across countries, from 47% to 100%. Among the 134 certified trainers, 46 (34%) had taught one CS course, 25 (19%) had taught two courses, 17 (13%) had taught three and the remaining 46 (34%) had taught four or more. Most of the individuals who taught more than four courses were advanced or master trainers. A total of 30 people completed the advanced training skills course and, of these, 26 (87%) were certified as advanced trainers. Six of the advanced trainers-five from Jamaica and one from Trinidad and Tobago-subsequently received training in curriculum development and were certified as master trainers.


The authors conclude that a TOT-based training program is an effective and sustainable method for rapid scale-up of VCT services and training capacity in large-scale VCT programs.

Quality Rating

There are no quality-rating scales for studies of this type. The sample for the telephone survey was limited to participants whose data were entered by the end of May 2005, who had provided contact information, and who worked at a site that agreed to participate in the survey. Therefore, it is possible that some people who were not contactable or who work at non-participating site were still providing VCT services. In addition, information on the work status of most people who had left the original site was not available, and for the purpose of analysis they were coded as not providing services. It is possible that these individuals as well were providing VCT services at another site. All of these factors may have led to an underestimation of the proportion of participants continuing to provide VCT services. This evaluation did not address the quality of the services provided or trainings conducted. Although some level of quality is assumed based on the training curriculum and methodologies used, the quality of services should be measured periodically, as feasible.

In Context

These findings are comparable to similar evaluations of TOT models, such as a recent evaluation of learning strategies used by UNICEF in resource-limited settings, which found "between 50 and 70% of the TOT trainees going on to provide training to their colleagues."(1) The same evaluation noted that training local professionals to train their colleagues is generally less expensive than sending national or international experts to conduct trainings.(1)

Programmatic Implications

Using local trainers to implement TOT has the advantages of building local capacity and ensuring the trainings have cultural relevance and application which will help to enhance learning. Thus, it is likely that the TOT model will continue to be applied in situations where hundreds of training sessions are needed to train thousands of people, and that efforts will be made to mitigate differences in quality through use of standardized competency-based curricula, well-designed training programs, and, when needed, performance measurement and quality improvement.


  1. UNICEF. Evaluation of UNICEF learning strategy to strengthen staff competencies for humanitarian response, 2000-2004. UNICEF 2005.