The feasibility and acceptability of collaborative learning in improving health worker performance on adolescent health: findings from implementation research in Moldova

Collaborative learning has been increasingly implemented in healthcare settings in recent years. Defined as an approach to teaching and learning in which groups of learners work together, collaborative learning typically involves group discussions, with participants cooperating to solve a problem, complete a task, or otherwise advance learning [1]. This approach appears to be effective in improving the performance of health workers, with a large systematic review conducted in low-resource settings showing greater effect from group processes, especially when combined with other approaches such as good quality training [2]. This finding was confirmed by a recent Lancet Global Health Commission on high quality health systems, which noted that, “District-led collaborative learning has the potential to foster improved quality through better system functioning and communication” [3].

Relatively little is known about the feasibility or effectiveness of collaborative learning to improve health worker performance in youth-friendly health services (YFHS), which aim to prevent, detect and treat health conditions among adolescents and youth by delivering health services in ways that are accessible and acceptable to young people themselves (i.e. they are able and willing to obtain them). Several countries have systematically scaled up YFHS in recent years, but consistent delivery of high quality services remains a key challenge [4].

This paper explores whether collaborative learning in YFHS is feasible and acceptable as a means for improving YFHS quality by examining recent experience in the Republic of Moldova, an ex-Soviet country in Eastern Europe, which has implemented collaborative learning across 39 YFHS as part of a national scale up of youth-friendly health services since 2012 (see Figs. 1 and 2) [5‐12]. We aimed to describe the characteristics of the collaborative learning approach implemented in Moldova, including the number of districts and YFHS involved, number of sessions, profile of participants and key themes of sessions. We also explored the key benefits and challenges of the collaborative learning approach for participants and YFHS.

The learning programme implemented in YFHS in Moldova is the first time collaborative learning methods have been used as a central component of a YFHS scaling up process. Our results confirmed that this approach is feasible, with the vast majority of YFHS successfully implementing CLS across Moldova. Our results also suggest that collaborative learning in YFHS is highly acceptable to both participants and moderators and appears to have benefits for both participants and the health services.

Key benefits of collaborative learning for session participants appear to include improved knowledge and use of evidence-based resources on adolescent health; strengthened teamwork and cooperation; and increased confidence to provide high quality, holistic care, including on sensitive topics such as sexuality. Collaborative learning appears to contribute to the commitment, confidence and ability of providers to deliver youth-friendly health services in accordance with quality standards and guidelines. The regular inclusion of themes such as family planning, violence and abortion is likely to have contributed to reported benefits around improved youth-friendly attitudes of providers, including on sensitive issues, and greater awareness and observation of confidentiality. Given that confidentiality and respect are consistently identified as two of the most important aspects of youth-friendly services by young people themselves, these findings suggest collaborative learning may be a valuable tool for ensuring that YFHS deliver truly youth-friendly care [17].

Collaborative learning also appears to have benefits for youth-friendly health services, including strengthening their position as trusted resource centres for adolescents and youth, improving cooperation on adolescent health, and increasing the number of beneficiaries. Indeed, collaborative learning participants reported high numbers of referrals to YFHCs. While our study could not verify that the collaborative learning approach resulted in increased numbers of referrals to YFHCs or usage of the services by young people, it is plausible that the involvement of key stakeholders from outside YFHCs such as teachers, school counsellors and religious leaders may have resulted in increased referrals and therefore increased usage. It is also likely that improvements in youth-friendliness and acceptability of care as a result of collaborative learning will have flow-on effects in terms of service usage, and in the longer term, sustainability of services. These findings are highly relevant given well-documented challenges in ensuring the quality, youth-friendliness, usage and sustainability of youth-friendly health services during national scale up processes [5, 18, 19].

Our results suggest that the collaborative learning approach may have system-wide benefits which are highly relevant to the Moldovan context. In a highly hierarchical and traditionally heavily hospital-based health system, learning in multi-disciplinary groups was a relatively new concept for many moderators and participants but appeared to be a key contributor to benefits around teamwork, inter-sectoral cooperation, and referral pathways. Improvements in provider knowledge and confidence to provide youth-friendly care are also likely to have a positive impact on job satisfaction – potentially a crucial factor in addressing high staff turnover and net emigration of trained health providers, and thus quality of health services [20, 21]. Ongoing challenges to the sustainability of collaborative learning in YFHS are likely to be posed by the lack of regulations mandating continued professional development of health providers, and insufficient dedicated funding for YFHCs to run collaborative learning sessions.

This study is the first to examine collaborative learning as part of a national scaling up process for YFHS and adds to existing evidence on the effectiveness of collaborative learning in other health settings. However, study limitations include that we were not able to assess whether collaborative learning directly resulted in higher quality, including youth-friendliness of services, increased referrals or usage, or the long-term sustainability of services. The question of cost was also beyond the scope of this study. Our findings may furthermore have been subject to selection bias, since questionnaire participants volunteered for the task and could be more likely to have strong feelings about collaborative learning (positive or negative).

Our results provide preliminary evidence for a range of potential benefits provided by collaborative learning, and confirm that such an approach is both feasible and acceptable when implemented as part of a national YFHS scale up process. On the basis of our results and existing evidence for the benefits of collaborative learning, similar approaches could be confidently adopted by YFHS in other settings. This study provides sufficient evidence to warrant further research in Moldova and elsewhere to examine whether collaborative learning fulfils its potential at the impact level – that is, by contributing to improved quality of care, greater youth-friendliness, increased referrals to and usage of services, and long-term sustainability.

Our results suggest that collaborative learning, when systematically implemented as part of a national scale-up process for YFHS, is both feasible and acceptable. The approach offers promising benefits to participants and YFHS that are likely to be highly pertinent to addressing some of the key challenges in successfully scaling up YFHS, namely ensuring quality of care and youth-friendliness, increasing utilisation, and achieving long term sustainability. While further research is required to confirm our results in other settings and to examine whether collaborative learning can truly deliver improvements in these areas, our study suggests that collaborative learning in YFHS is a valuable tool for achieving high quality, youth-friendly services for all young people.