Content uploaded by Susannah Mayhew
Author content
All content in this area was uploaded by Susannah Mayhew on Jul 17, 2015
Content may be subject to copyright.
Available via license: CC BY 2.0
Content may be subject to copyright.
Content uploaded by Manuela Colombini
Author content
All content in this area was uploaded by Manuela Colombini on Jul 01, 2014
Content may be subject to copyright.
R E S E A R C H A R T I C L E Open Access
Exploring experiences in peer mentoring as a
strategy for capacity building in sexual
reproductive health and HIV service integration
in Kenya
Charity Ndwiga
1*
, Timothy Abuya
1
, Richard Mutemwa
2
, James Kelly Kimani
1
, Manuela Colombini
2
,
Susannah Mayhew
2
, Averie Baird
1
, Ruth Wayua Muia
3
, Jackline Kivunaga
1
, Charlotte E Warren
1
and on behalf of the Integra Initiative
Abstract
Background: The Integra Initiative designed, tested, and adapted protocols for peer mentorship in order to
improve service providers’skills, knowledge, and capacity to provide quality integrated HIV and sexual and
reproductive health (SRH) services. This paper describes providers’experiences in mentoring as a method of
capacity building. Service providers who were skilled in the provision of FP or PNC services were selected to
undergo a mentorship training program and to subsequently build the capacity of their peers in SRH-HIV
integration.
Methods: A qualitative assessment was conducted to assess provider experiences and perceptions about peer
mentoring. In-depth interviews were conducted with twelve mentors and twenty-three mentees who were
trained in SRH and HIV integration. Interviews were recorded, transcribed, and imported to NVivo 9 for analysis.
Thematic analysis methods were used to develop a coding framework from the research questions and other
emerging themes.
Results: Mentorship was perceived as a feasible and acceptable method of training among mentors and
mentees. Both mentors and mentees agreed that the success of peer mentoring largely depended on cordial
relationship and consensus to work together to achieve a specific set of skills. Mentees reported improved
knowledge, skills, self-confidence, and team work in delivering integrated SRH and HIV services as benefits associated
with mentoring. They also associated mentoring with an increase in the range of services available and the number of
clients seeking those services. Successful mentorship was conditional upon facility management support, sufficient
supplies and commodities, a positive work environment, and mentors selection.
Conclusion: Mentoring was perceived by both mentors and mentees as a sustainable method for capacity
building, which increased providers’ability to offer a wide range of and improved access to integrated SRH and
HIV services.
Keywords: Mentoring, Integration, HIV, Sexual reproductive health, Postnatal care, Family planning
* Correspondence: cndwiga@popcouncil.org
1
Population Council Nairobi, Nairobi, Kenya
Full list of author information is available at the end of the article
© 2014 Ndwiga et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited.
Ndwiga et al. BMC Health Services Research 2014, 14:98
http://www.biomedcentral.com/1472-6963/14/98
Background
Integrating sexual and reproductive health (SRH) and HIV
services has the potential to increase service utilization,
improve quality of services and efficient use of resources,
and enable health systems to respond to client needs,
leading to improved client satisfaction [1-5]. However,
knowledge gaps among frontline providers constrain
service provision necessitating training on additional
knowledge and skills for SRH and HIV integration [6].
Traditional approaches to capacity building, such as
offsite training workshops, are costly, interrupt service
delivery, are not conducive to the sharing of newly ac-
quired skills and knowledge between colleagues, and,
therefore, have limited sustainability [7-9]. Training in
low resource settings is further complicated by a crisis
in human resources for service provision [7-10], hence
the need for innovative approaches to improving provider
skills without compromising service delivery. Mentorship
is one such approach, which harnesses the potential of
service providers and is likely to enhance the quality of
service provision in integrated service settings.
While there is no universal consensus on the definition
of mentorship [11], mentoring is an interactive, facilitative
process meant to promote learning and development
[11,12]. Mentorship can either be formal (generally de-
signed for a predetermined length of time) or informal
(based on good rapport and mutual attraction, which
tends to develop slowly) [13]. It occurs when a more
skilled or experienced person is paired with a less skilled
person with the agreed-upon goal of having the less skilled
person develop specific abilities to reach long-term objec-
tives [11]. Workplace mentorship has been associated with
a wide-range of positive outcomes [14], including in-
creased confidence and self-esteem among mentored indi-
viduals compared to their non-mentored counterparts
[15]. Mentees also gain more knowledge, experience less
stress and conflict, are more satisfied with their jobs, and
are less likely to leave their organizations compared to
non-mentees [16].
In Kenya, the Integra Initiative aims to strengthen the
evidence base on the impact of integrating family plan-
ning (FP), postpartum/postnatal care (PNC) and HIV
services in sub-Saharan Africa through assessing two
models of integration: 1) integration of FP and HIV ser-
vices referred here as FP model and includes HIV testing,
STI screening and management, cervical cancer screening,
condom promotion within FP consultations, and referral
for HIV services; and 2) The integration of postnatal care
(PNC) and HIV services referred as PNC model and in-
cludes the provision of postnatal services to mother and
baby, postpartum FP services, HIV testing for mother and
infant, and referrals for HIV and other services.
Across the two models, one component of the inter-
vention was to build capacity of health workers to
provide integrated SRH /HIV services. In collaboration
with the Ministries of Health Kenya the Integra Initiative
developed mentorship training package. Although stud-
ies have shown that mentoring improves provider skills
and attitudes [14,17], there is little evidence on the
process and dynamics of implementing a mentoring pro-
gram to build capacity for SRH and HIV integration.
This paper explores the experiences of mentors and
mentees from selected health facilities in Kenya where
SRH-HIV service integration is ongoing. The paper ad-
dresses the following research question “how does men-
toring work in SRH and HIV service integration? We
describe the process, enabling factors, benefits, and chal-
lenges of peer mentoring in resource poor settings.
The mentoring process
Within the Integra Initiative, the mentoring process re-
ported in this paper is based on our reflections within
the context of the research and its evaluation conducted
within the study. The study jointly with Ministry of
Health, Kenya developed a framework as shown in
Figure 1 that followed three key steps- 1) develop-
ment of the mentorship program, 2) implementation
of the mentorship program and 3) assessment and
evaluation. Each of these steps comprised sub-activities
as such advocacy for mentoring among stakeholders; con-
ducting a health facility assessment (situational analysis);
development and adaptation of mentoring tools and mate-
rials; selection and induction of mentors; conducting peer
mentoring sessions in FP, PNC, and HIV service settings;
monitoring and supervision of mentoring; and assessment
and certification of mentees. These steps were important
for standardizing the mentoring approach as training
model.
Mentorship activities were implemented between
August 2009 and July 2010. Prior to the intervention,
the Integra Initiative met with providers, health facility,
district, and regional health managers, SRH and HIV
trainers, program managers, and policymakers to obtain
consensus on the use of mentoring as a training method.
Simultaneously, a health facility assessment was con-
ducted; this included an inventory to identify the avail-
ability of equipment and supplies; an evaluation of
providers’knowledge and skills, and observations of
client-provider interactions. Guidelines and training ma-
terials on HIV, FP, postpartum and newborn care, cancer
of the cervix, were reviewed and adapted to develop spe-
cific mentoring tools (Consensus was reached on the
core knowledge and skills needed to attain competency
in the provision of integrated HIV and SRH services.
Mentoring tools were initially pre tested over a two-
month period in six intervention facilities in both PNC
and FP integration models (12 in total). The following
tools were then revised and finalized: the mentees initial
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 2 of 11
http://www.biomedcentral.com/1472-6963/14/98
self-assessment; the mentor’s checklist; the mentee log-
book; the mentor’s monthly summary sheet; and a job
aid on how to use the mentoring tools (Table 1).
Eligibility criteria for mentor selection included experi-
ence in providing HIV and FP or PNC services, the abil-
ity to transfer knowledge and skills through behaviour
modelling, and a willingness to train others. Mentors
from the FP-HIV model had prior training in FP and the
use of the Balanced Counselling Strategy (BCS) Plus
toolkit for family planning counselling. BCS Plus toolkit
provides counseling information on SRH and HIV ser-
vices and step-by-step guidance for providers on how to
use the toolkit during consultations [18]. The mentors
participated in a five-day induction workshop, which fo-
cused on skills standardization in FP and HIV service
provision. For the PNC-HIV integration model, an extra
five-day workshop on targeted PNC and the use of BCS
Plus was followed by a five-day induction workshop on
PNC and HIV service provision.
Each mentor identified a mentee and administered a
self- assessment tool to determine his or her individual
learning needs. Based on the results, both the mentor
and the mentee set learning objectives and agreed on a
suitable number of contact hours, which usually took
place in the afternoon when facility workloads typically
decreased. On average the mentors and the mentees had
100 contact hours over a 4 to 6 months period to
achieve the recommend SRH and HIV knowledge and
skills competency. After the completion of theoretical
trainings, skills demonstrations, return demonstrations
and coaching for specific RH and HIV skill sessions were
held for mentees. These were followed by clinical prac-
tical sessions on clients.
To monitor the effective transfer of knowledge and skills,
mentors were observed by supervisors during mentoring
sessions. Supervisors conducted verbal question and an-
swer sessions for mentees during site visits and provided
knowledge and skill update sessions to both mentors and
mentees when necessary. Mentees conducted self and peer
skills assessments on a day-to-day basis using learning
guides and checklist, and used logbooks to record which
competencies were completed satisfactorily. Once mentors
were satisfied that mentees had acquired the recommended
competencies, mentees were assessed by an external team.
Mentorship Programme
implementation
County and facility level
Mentors selected
Mentor Induction Workshop
5 days
Mentorship Programme with mentees
3 to 6 months
Facility managers support and supervise
Development of
Mentorship Programme
National, county and district level
Need identified for Integrated SRH/HIV
and Capacity-Building Programme
Advocacy meetings held;
financial and political support garnered
Situation analysis
Materials, tools, and supplies developed and collected
Mentorship Programme
assessment and
evaluation
National, county, and
facility leve l
Mentee assessment and certification
Mentee–Mentor internal evaluation
Programme evaluation
Dissemination of results
Figure 1 Mentorship Programme Implementation.
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 3 of 11
http://www.biomedcentral.com/1472-6963/14/98
Table 1 Description of mentoring tools
Tool Who/When used/Filled How Point of use Comments
BCS Plus Toolkit Mentors and mentees during
service provision
Use algorithm providing step-by-step guidance
to provide integrated SRH-HIV services during
consultation, refer to trainee guides on how to
implement material in the toolkit
In clinical area (FP, PNC, ART, MCH, VCT)
or during training sessions
Contains a series of illustrative counselling
cards covering a range of topics, such as
types of FP methods, STI and HIV risk
assessment, and HIV counselling and
testing
Mentees initial
assessment pre-test
Mentee Answers questions and returns responses to
the mentor
In clinical area (FP, PNC, ART, MCH, VCT) The mentor gives each mentee to assess
his/her level of knowledge before starting
mentoring
Mentees clinical
protocol
Mentor when mentoring/coaching
the mentee on clinical procedures
Observes mentee performance during clinical
procedures in the protocol and scores according
to the key provided in the integrated SRH/HIV
clinical assessment tool
In clinical area (FP, PNC, ART, MCH, VCT) The mentor maintains a facility file for all
procedures observed
Mentor logbook Mentee after client visit Summarizes skills acquired after every clinical
procedure
In clinical area (FP, PNC, ART, MCH, VCT)
or in offices
Maintained by mentees and is availed to
supervisors as required
Monthly summary
sheet
Mentor at end of the month Records of all mentoring sessions with her/his
mentee(s) and summarizes all activities
In clinical area (FP, PNC, ART, MCH, VCT)
or in offices
Original copy sent to RH coordinator and
one copy kept on file
Integrated SRH/HIV
clinical assessment
tool
Mentor or regional/national
level RH coordinator during
mentee assessments
Used to evaluate and mark all procedures
performed during mentee assessment, a score
of 85% means the mentee has passed and
can be certified
In clinical area (FP, PNC, ART, MCH, VCT) A copy is sent to the provincial/national
level as evidence of the exam
Mentees guide Mentees for continuous
reference
Reference material Any instance/location when making
reference to course content
Maintained by mentees
Mentees guide Mentors for continuous Reference material Any instance/location when making Maintained by mentors
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 4 of 11
http://www.biomedcentral.com/1472-6963/14/98
Methods
This qualitative study was nested within a larger quasi-
experimental evaluation of the Integra Initiative- described
elsewhere [19]. The Integra Initiative aims to strengthen
evidence on the impact of integrating SRH and HIV ser-
vices in Kenya. Twelve facilities for each integration model
(FP or PNC) were purposefully selected to participate
based on: client loads of more than 50 per month; facilities
with a minimum of two health workers providing FP
services; providing a range of SRH services; and not
having currently integrated services.
A team of trained researchers conducted in-depth in-
terviews (IDIs) with 23 mentors and 12 mentees provid-
ing either FP-HIV or PNC-HIV integration models. We
employed purposive sampling to select the study partici-
pants. Mentors that had successfully trained at least one
service provider using mentoring a methodology for cap-
acity building were included in the study. Mentees that
had been trained and certified as competent in RH and
HIV services integration through mentoring were in-
cluded in the study. Mentors and mentees on duty on
the day of the interview and consenting to the study
were interviewed. Pre-tested interview guides focused on
providers’understanding of the mentoring approach as a
method of training, the procedures used in mentoring
sessions, the benefits of mentoring in SRH and HIV in-
tegration, and challenges faced with the mentoring
methodology.
IDIs were conducted in English and lasted approxi-
mately 40 minutes. Written informed consent was ob-
tained from all respondents in the study. Interviews
were recorded, transcribed in Microsoft Word, and
imported to NVivo 9 software (QSR international, 2007)
for management and analysis. A thematic framework ap-
proach was used to develop a coding framework from
the research questions and other emerging themes. Data
was coded into themes that emerged from the transcripts.
An initial thematic framework was derived through an it-
erative process and more themes were included as more
data were examined. Reflexivity was enhanced through
consultations with other members of the research team.
Finally, analysis charts were developed to further refine
the findings. Quotes selected in presenting results are
based on their re- occurrence among respondents, im-
portance, relevance and divergence of opinion on the
emerging themes.
Ethical considerations
Ethical and research clearance for the study were
granted by the Population Council Institutional Review
Board (Approval No. 443 and 444), the Ethics Review
Committee of the London School of Hygiene & Tropical
Medicine (LSHTM) (approval number 5426) and the
Kenya Medical Research Institute (Approval No. SCC/113
and SCC/114). The study is part of a wider research pro-
ject under the registration number NCT01694862.
Results
In total, 35 service providers were interviewed of whom
twenty-three were mentors and twelve were mentees.
The average age of mentors was 40 years and for men-
tees 36 years. Mentors had worked at their current facil-
ity for an average of nine years and mentees for seven
years. Most providers were either registered nurses/mid-
wives or enrolled nurses/midwives (Table 2).
Perceptions of the mentoring process
Mentors induction
The majority of mentors interviewed felt that they were ad-
equately prepared for the mentorship induction process,
“Yes, what I would say it [induction] was adequate
because I already had knowledge and skills. …the
long-term methods, I had the skills, so the update to
me was adequate”[Respondent C04-03, Mentor, FP
site].
Table 2 Provider characteristics
Mentees
(N = 23)
Mentors
(N = 12)
Total
Position n n N
Enrolled nurse/midwife 7512
Registered nurse/midwife 12 5 17
BSCN Nurse 011
Clinical officer 202
Other 213
Total 23 12 35
Age n n N
<=30 yrs 538
31-35 yrs 347
36-40 yrs 112
41-45 yrs 639
46-50 yrs 606
> 50 yrs 213
Total 23 12 35
Time in facility n n N
<1 yr 549
1-5 yrs 426
6-10 yrs 628
11-15 yrs 011
16-20 yrs 0s 0 0
> 20 yrs 516
Total 20 10 30
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 5 of 11
http://www.biomedcentral.com/1472-6963/14/98
However, some felt that the five-day induction did not
allow for sufficient practice on skills previously trained,
but not applied regularly. For instance, one mentor said
that the induction period was too short for the IUCD
practical sessions.
“…At first I did not have the right skills and we were
taught for only four days so I had to come back to the
facility and take a month of practising IUCD insertion
before I could mentor somebody”[Respondent C05-01,
Mentor, FP site].
This demonstrates that even if mentors felt that they were
fully competent to mentor, in some cases it still took time
for them to master and feel confident enough to train others
on specific skills. Some mentors required additional support
in specific skills, such as screening for cervical cancer lesions
using visual inspection with acetic acid/visual inspection
with lugols iodine (VIA/VILI). This technique was recently
introduced to Kenya [20]. One PNC mentor stated:
“…even after the training I had to go back to xxxx to
practice for a week before I could mentor on VIA/VILI
skill”[Respondent E06-01].
Similarly most mentees from both the FP and PNC sites
felt that mentors were adequately prepared to mentor them:
“My mentor was knowledgeable. When mothers came
with complications such as those with IUCDs or those
[with] implants so we used to ask her [mentor] what to do
and she told us…” [Respondent C01-05, mentee, FP site].
While another mentee stated
“he (mentor) was good in demonstrating the use of
BCS + toolkit, and although it initially looked hard to
build confidence, within a short time I used it with
ease”[Respondent E06-03, Mentee, PNC site].
However, some mentees felt that there were areas
where the mentor was not always comfortable such as
neonatal care and screening for cervical lesions using
VIA/VILI method.
“…her (mentor) demonstration was not right. I knew it
because I had gone for a recent update in neonatal
care but I told her (mentor) about the right thing.”
[Respondent E05-03, Mentee, PNC site]
A mentee from the family planning sites said
“..she (mentor) was okay in other areas but for this
VIA/VILI…she kept on referring to the Job Aids on the
walls and I wondered if we are doing well,…
[Respondent C09-02]
Mentees selection
To introduce mentoring, most mentors began with identi-
fying a willing mentee from the same facility. Interviews
with mentors indicated that this selection process allowed
them to build a relationship of mutual trust, which was
conducive for effective learning and development:
“Now, after the training [induction] I had to choose
the mentees.…I had to choose the person who I think
would better benefit from my experience…I sold the
idea to her first, for her to learn”[Respondent E01-02,
mentor, PNC site]
The majority of the mentees concurred with the above
statement and explained they were recruited by asking
to volunteer.
“Our mentor told us to volunteer for the mentoring, so
I did since I was interested in learning the skills in
long acting FP methods and this was good chance for
me”.[Respondent C02-04, mentee, FP site]
Enabling factors in skills transfer during the mentoring
process
Trust and mutual respect
Majority of the mentors and mentees reported that
mentoring sessions were cordial. As one FP sites mentee
described, respect for the mentor was important for the
skill transferring.
“You know although were working together as
colleagues, I respected her as one would respect her
teacher, I had to humble myself to learn”.[Respondent
C01-03, mentee, FP site]
A mentor, PNC site also said:
“I maintained a friendly atmosphere and we worked
well as colleagues.... but I had to be firm to ensure that
they (mentees) completed their assignments and kept the
schedule of our contact time”[Respondent E02-04].
Most of the mentors thought that factors facilitating
the mentorship process included a mentee with an inter-
est in learning and having a complementary working re-
lationship built on trust and mutual respect. As one FP
mentor describes the mentorship process:
“You take the pain of doing everything just to make
sure this mentee learns......., but mostly it depends on
the interest of the mentee”[Respondent C01-06].
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 6 of 11
http://www.biomedcentral.com/1472-6963/14/98
Another Mentor from PNC site said, “…My relationship
with my mentees…is very good because we have never
quarreled at any time [Respondent E02-04].
Most mentees noted that encouragement from men-
tors, and patience and cooperation (with both clients
and mentors) facilitated the transfer of skills throughout
the mentorship process.
“When the mentor came across a good learning case
during her work, she asked the client if I could perform
the procedure while a mentor guided me.... most
clients agreed’[Respondent E 04–02, mentee, PNC
site].
Support and flexibility of managers in mentoring
Some mentors stated that departmental heads supported
the mentorship process by providing flexible schedules
so that mentees could practice their acquired skills.
“Although there was shortage of staff, my in charge
allowed me to take day shift for six months to avail
myself for the mentees’practical sessions during the
day”[Respondent C01-06, mentor, FP site].
Appreciation for the mentorship and mechanisms for
consistent supervision helped to facilitate this higher-
level support. For example:
“The in-charge was supporting us because when you
tell her we don’t have Jadelle she could go to district
headquarters and borrow and bring to us for learning.”
[Respondent E01-02, mentee, PNC site]
In a few instances, the facility managers re-deployed
mentees before completion of all the mentoring sessions
thus disrupting the training. For example
“There was a staff change-over, one of the mentee was
moved to the operating theater, and it was difficult to
continue with training. She and I pleaded with in
charge to let her finish but this was not possible, so she
took night duty and completed when she was off duty..
it was hard for her”.[Respondent 60–01, mentor,
from FP sites]
Benefits of mentoring
Individual motivation
Within health facilities, mentoring provided an oppor-
tunity for the majority of mentors to be recognized by
their managers.
“I never thought i could train any one, let alone be
recognised by the facility in charge and other providers
in the district for my work”[Respondent C01-05, men-
tor, FP sites].
Majority of the mentees reported that as a result of men-
toring the mentees reported that they became motivated to
provide quality services to clients and were less likely to
refer clients to higher-level facilities since they felt they
were more competent with provision of additional skills.
“The other thing is they appreciate me for what I have
done. …They are in a position to come and ask for
more services here. Before they used to go to clinicians
but nowadays they come to FP clinics if they have
problems like STI”[Respondent C01-01, Mentee, FP
site].
Furthermore, they reported offering a wider scope of
services. Majority of the mentees reported said that this
in return, facilities experienced gains from increased rev-
enue, particularly from long-term FP methods. The in-
crease in the scope of services provided, also saved
clients time and money:
“[Now] we have IUCD clients and before they never
used to accept. Also the workload used to be high but
now the queues for FP [services] are shorter but we
have more clients for VIA/VILI…” [Respondent C02-05,
mentor, FP site]
Improved provider-client relationship
The provision of broader integrated HIV and SRH ser-
vices led to improved relationships between clients and
providers:
“…Because of talking to these mothers, giving them the
good services, the long-term methods and screening
them for cervical cancer, TB, STI, HIV testing, they
have learnt to accept us and they are so kind. They
have learnt to love us –not like before when they used
to hate us and talk to us in a very rude way”
[Respondent C0-03, mentee, FP site].
Mentoring also improved provider-client communica-
tion through improved counselling. This enabled clients
to be open about their health issues and service prefer-
ences, and often facilitated client diagnosis and improved
clients’understanding of the FP methods available. For ex-
ample one PNC mentee said:
“Once you take counselling in a proper way the client
is able to expose the deep feelings within her and you
are able to offer the services freely because the client
will have given her choice on the method.”
[Respondent E01- 01]
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 7 of 11
http://www.biomedcentral.com/1472-6963/14/98
A mentor also remarked that by offering integrated
services providers were now able to help women save
some money.
“…We are saving the mothers the money for transport
and method that they had to use every month. They
are also appreciating and it has helped to improve the
health of our mothers.”[Respondent E05-01, mentor,
PNC site]
Challenges of mentoring
Competing job priorities and insufficient communication
between facility managers and providers demotivated
some mentors from initiating mentoring. A FP mentor
stated:
“When I came from the mentors training I explained
to the facility in charge and my colleagues what was
expected of me. I waited for volunteers so that I
could start mentoring, but wacha! (expressing
disgusts) they were un bothered,…Ionlystartedafter
the supervisors came.”[Respondent C01-06, mentor,
FP site]
Another key challenge that mentors observed was the
high workload due to staff shortages. This often limited
the contact hours between mentors and mentees, as de-
scribed by one mentor:
“Different working schedules and high workload…
maybe you plan to have a session on Saturday but it
becomes so busy that you miss the time to sit and
share or to show a certain mentee a skill.”
[Respondent, E01-02, mentor, PNC site]
Almost all the mentors pointed out that their contact
time was limited due to a difficulty in coordinating her
schedule with that of her mentee:
“…Now because of the shortage of staff I had a very
rough time trying to get time with the mentees because
when I am available the mentees are on night duty …
so you are getting very few hours for you to sit down
with your mentees”[Respondent C03-04, mentor, FP
site].
A few mentors concurred that they did not use the
checklist during all the mentoring sessions.
“sometimes you could get a good case to teach with
but the two of you (mentor and mentee) do not have
the mentors checklist near at the time, so you just
continue......you may miss a few steps but you have
taught”[Respondent E03-01, mentor, PNC site].
In these cases, mentors supervisors took time to cor-
rect the mentors during the on-site assessment or/and
asked mentors from other facilities to support training
in these specific skills if more coaching was required. In
cases where mentors were junior in professional rank to
a mentee, some mentees with higher ranks expressed
discomfort:
“…She was my junior. She was there training me. But
now I had to deal with that…I had to show…I had to
make sure that she doesn’t feel like she’s my junior
training no, ‘hiyo tuliweka kando’[we put that aside]
for learning to take place”[Respondent E01-06, mentee
PNC site].
Mentees expressed some concern about the orienta-
tion process, which they felt did not provide sufficient
information on what would be expected of them:
“I wish we would have been…told what amount of
time was required from us. We were not told the date
when we would be assessed. It is good to know when
you are starting and for how long so that you can have
a time limit [Respondent E02-01 mentee PNC site].
Some mentees also had difficulty learning less com-
mon procedures such as cervical cancer screening, syn-
dromic management of STIs, and IUCD insertions.
Mentees described their experiences learning these
procedures:
“I had challenges inserting IUCDs because clients were
not used to the method, yet we were required to
practice a lot. Screening for cancer of the cervix was
also not easy. We only used to hear about [it] so when
the mentor trained me, it was not easy…” [Respondent
C01-05, mentee, FP site].
A lack of clients demanding relevant services also hin-
dered mentees’ability to acquire new skills:
“…having that patience to wait for that client and wait
to be shown…the availability of the clients themselves
because if you don’t get a client then it is not easy to
learn”[Respondent E01-02, mentee, PNC site].
Limitations for the mentee arose if mentors did not
follow the recommended steps in training mentees for
all the skills and techniques included in the mentoring
tools as components of SRH and HIV integration. One
FP mentee expressed,
“So we faced great difficulties. I am being assessed with
the new techniques and she has taught me with the
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 8 of 11
http://www.biomedcentral.com/1472-6963/14/98
old techniques [Respondent C02-04].”Another said,
“when we began, we were not following the mentors’
checklist, so when the supervisors asked me for a
demonstration of the implants insertion, I missed a
few step and I was corrected.... my mentor and I had
only used the checklist once”[Respondent E04-02,
mentee, PNC site].
In some instances the mentors and mentee experi-
enced similar challenges. Some mentees said that short-
ages of commodities affected the amount of training
time for mentees and resulted in delayed certification.
“I had only done three case of Jadelle and then the
stock finished, I waited for a month before I could
continue with learning that procedure”[Respondent
E05-03, mentee, PNC site]
A FP mentor recalled:
“We had stock-outs of some of the methods that we
were promoting like the Jadelle, Depo, and also the
solutions for doing the cervical cancer screening. So
when you stay for three weeks without such commodities,
even mentoring becomes a problem since you do not have
all the things required to work.”[Respondent, C01-05]
Additionally, some also stated that inadequate space
for service provision, particularly private rooms for
counseling, slowed the process. One PNC mentor ex-
plained the situation:
“We do not have enough rooms. We may train all our
staff, but still the rooms remain two. We need privacy.
We need room for counseling the client and it is not
there”[Respondent E01-03]. Another PNC mentee
stated “our room has very limited space when we
(mentors and mentee), the mother and the baby we
have no space but we had just to learn”[Respondent,
E05-03].
Discussion
The objective of this study was to explore the experi-
ences of mentors and mentees from selected health facil-
ities in Kenya where SRH-HIV service integration is
ongoing. The primary aim of introducing mentoring was
to strengthen providers’capacity (knowledge and skills)
to provide the recommend package of SRH and HIV in-
tegrated services. From the both the mentors and men-
tees experiences four key components were critical in
enabling effective skills transfer: 1) support and flexibility
by managers; 2) adequate commodities, supplies, and hu-
man resources; 3) mentors selection, induction and use of
mentoring tools; and 4) positive work environment.
However, both mentors and mentees experienced chal-
lenges, which limited the effectiveness of the approach.
These challenges included, erratic supplies and com-
modities, high client case load, shortage of staff, and
inadequate skill and/or lack confidence by mentors in
training certain skills. Facility-specific solutions to these
challenges were identified between mentor and mentees,
and the Integra Initiative and/or facility managers offered
support as needed.
Selection of mentors is critical in ensuring smooth
transfer of knowledge and skills. We found that the ma-
jority of the mentors were well selected and thus effect-
ive in mentoring. However, there were some cases in
which mentors felt they were not sufficiently confident
or competent to conduct procedures, such as cervical can-
cer screening or IUCD insertion. Further, the findings
seem to suggest that some mentors did not constantly use
the mentoring tools and potentially transferred incorrect
knowledge and skills to the mentees. This may have been
because the five-day mentor training sessions did not
allow for enough practical application of these newly ac-
quired or rarely used skills. In addition, a few of them did
not adhere to the mentoring standards. Although, this was
addressed during the supervisors visits through onsite
training, perhaps there is need to ensure these training
gaps are addressed in the course of mentoring. Further, all
mentors should adhere to use of mentoring checklist in
order to ensure that mentees are assessed on sequence of
step in procedures that they may not have been trained
on. These findings seem to concur with a study on. use of
on job training on post abortion care in Nepal that ob-
served maintaining quality of on-job-training is difficult,
particularly if on wide scale [21].
Before initiating a mentoring strategy, it is necessary
to have support and endorsement from local facility and
high-level managers to ensure a smooth rollout at the
facility-level. Mentors and mentees noted that the flexi-
bility of supervisors and managers facilitated the neces-
sary adjustments to their work schedules, allocation of
clients and commodities to ensure mentorship on neces-
sary skills, and contributed to a positive learning and
teaching environment. World Health Organization (WHO)
guidelines on clinical mentoring underscores the need
to involve managers at all levels of health care in order
to institutionalise mentoring within the public health
system [22].
Mentoring was largely reported as feasible and accept-
able by both the mentors and the mentees in the study.
However, chronic shortages of human resources relative
to client loads rendered it difficult for mentors and men-
tees to coordinate their schedules, which limited contact
time. Inadequate infrastructure and critical supplies can
also hinder the ability of mentees to acquire new skills.
For example, the erratic supply of cervical cancer
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 9 of 11
http://www.biomedcentral.com/1472-6963/14/98
screening reagents reduced the amount of practice time
mentees had to develop and advance their skills and lim-
ited the package of integrated services providers were
able to offer clients. Peer mentoring as a training strat-
egy is limited by human resources crisis and the ever
growing volume of clients that require the services [23].
Where facility managers were committed to implement-
ing the mentorship approach they made deliberate ef-
forts to obtain supplies and commodities –even from
nearby facilities if needed –and shortages and stock-
outs were limited.
The findings further demonstrate that in a few isolated
cases mentoring sessions would reduce manpower (since
two providers - mentor and mentee would be with the
same clients) and this disrupted services delivery at the
facilities, countering the intended effects of the mentor-
ing approach. However, mentoring resulted in improved
scope of services as the provider offered a wider range of
services after the mentoring process was completed. The
findings also demonstrate that mentoring as an approach
can be used to improve providers’technical skills that
are one of the major challenges in human resources for
health. Mentorship created a sustained mechanism of
capacity building for knowledge and skills in SRH/HIV
integration despite the low staffing levels. It ensures con-
tinuity of services and learning at the same time for the
staff and thus can be applicable in low resources settings.
A sense of motivation and willingness to improve skills
among mentees and mentors cultivated positive learning
environments in facilities. It also developed healthy relation-
ships among providers prospectively leading to increased
confidence in performing the skills and commitment to pro-
viding quality services. In other studies that examined factors
associated with working environment and job retention of
health care providers education achieved while on the job
was found to be associated with job satisfaction [24-26]. The
provision of learning opportunities through mentoring
decreases provider anxiety about the future, satisfies
career development needs, and creates a high level of
job satisfaction [14,27].
Mentoring also encouraged performance feedback,
intra-staff communication, and prompted opportunities
for facility staff to offer the necessary support. These on-
the-job features are critical for enabling service providers
to establish a sense of organizational identity and be-
longing, which increases staff retention [17].
Conclusion
Overall, most providers perceive peer mentoring to be
an effective and feasible approach for capacity building
in the context of integrated SRH and HIV services. The
benefits of mentoring are particularly relevant for set-
tings with moderate or high HIV prevalence, limited fund-
ing for provider capacity building and staff shortages.
However, the findings from this qualitative study under-
score the need for flexibility and cooperation among peers
as well as managers when implementing mentorship.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
CEW and SM conceived of the study idea and critically reviewed the
manuscript. CN, RM and JK developed and pre-tested the in-depth interview
guide. CN and TA analysed the data and drafted initial manuscript. JJK, and
AB critically reviewed the manuscript. MC and RM critically reviewed and
edi ted the manuscript. CN and RWM coordinated the mentoring implementation
activities. JK coordinated data collection fieldwork. All authors read and approved
the final manuscript.
Acknowledgements
This project was supported by grant number 48733 from The Bill and
Melinda Gates Foundation. The content is solely the responsibility of the
authors and does not necessarily represent the official views of the funding
agency. The authors thank all the public health facilities and health care
providers in Eastern and Central Provinces of Kenya, who facilitated and
granted interviews during data collection phase of the study.
Author details
1
Population Council Nairobi, Nairobi, Kenya.
2
London School of Hygiene and
Tropical Medicine, London, UK.
3
Ministry of Health, Nairobi, Kenya.
Received: 12 April 2013 Accepted: 20 February 2014
Published: 1 March 2014
References
1. Church K, Mayhew SH: Integration of STI and HIV prevention, care, and
treatment into family planning services: a review of the literature. Stud
Fam Plan 2009, 40(3):171–186.
2. Dehne KL, Snow R, O'Reilly KR: Integration of prevention and care of
sexually transmitted infections with family planning services: what is
the evidence for public health benefits. Bull World Health Organ 2000,
78(5):628–639.
3. Spaulding A, Brickley D, Kennedy C, Almers L, Packel L, Mirjahangir J,
Kennedy G, Collins L, Osborne K, Mbizvo M: Linking family planning with
HIV/AIDS interventions: a systematic review of the evidence. AIDS 2009,
23(Suppl 1):S79–S88.
4. Dudley L, Garner P: Strategies for integrating primary health services in
low- and middle-income countries at the point of delivery. Cochrane
Database Syst Rev 2011(7). Art. No.: CD003318. DOI: 10.1002/14651858.
CD003318.pub3.
5. Liambila W, Askew I, Ayisi R, Gathitu M, Mwangi J, Homan R: Feasibility,
Acceptability, Effect and Cost of Integrating Counseling and Testing for HIV
Within Family Planning Services in Kenya. FRONTIERS Final Report.
Washington DC, USA: Population Council; 2008.
6. WHO: WHO Recommendations for Clinical Mentoring to Support Scale-up of
HIV Care, Antiretrov Iral Therapy and Prevention in Resource-Constrained
Settings. 20 Avenue Appia, 1211 Geneva 27, Switzerland: World Health
Organization; 2006.
7. Chankova S, Muchiri S, Kombe G: Health workforce attrition in the public
sector in Kenya: a look at the reasons. Hum Resour Health 2009, 7:58.
8. Luoma M, Doherty J, Muchiri S, Barasa T, Hofler K, Maniscalco L, Ouma C,
Kirika R, Maundu J: Kenya Health System Assessment 2010. Bethesda, MD:
Health Systems 20/20 project, Abt Associates Inc; 2010.
9. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, Cueto M,
Dare L, Dussault G, Elzinga G, Fee E, Habte D, Hanvoravongchai P, Jacobs M,
Kurowski C, Michael S, Pablos-Mendez A, S ewankambo N, Solimano G,
Stilwell B, de Waal A, Wibulpolprasert S: Human resources for health:
overcoming the crisis. Lancet 2004, 364(9449):1984–1990.
10. Smith MK, Henderson-Andrade N: Facing the health worker crisis in developing
countries: a call for global solidarity. Bull World Health Organ 2006, 84(6):426.
11. Gagliardi AR, Perrier L, Webster F, Leslie K, Bell M, Levinson W, Rotstein O,
Tourangeau A, Morrison L, Silver IL, Straus SE: Exploring mentorship as a
strategy to build capacity for knowledge translation research and
practice: protocol for a qualitative study. Implement Sci 2009, 4:55.
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 10 of 11
http://www.biomedcentral.com/1472-6963/14/98
12. Karcher MJ, Kuperminc GP, Portwood SG, Sipe CL, Taylor AS: Mentoring
programs: a framework to inform program development, research, and
evaluation. J Community Psychol 2006, 34(6):709–725.
13. McDonald J: Mentoring: An Age Old Strategy for a Rapidly Expanding Field: A
What, Why and How Primer for the Alcohol and Other Drugs Field.
Adelaide, Australia: National Centre for Education and Training on Addiction
(NCETA); 2002.
14. Eby LT, Allen TD, Evans SC, Ng T, Dubois D: Does mentoring matter? A
multidisciplinary meta-analysis comparing mentored and non-mentored
individuals. J Vocat Behav 2008, 72(2):254–267.
15. Ragins BR, Cotton CJ, Miller JS: Marginal mentoring: the effects of type of
mentor, quality of relationship, and program design on work and career
attitudes. Acad Manag J 2000, 43(6):1177–1194.
16. Fagenson-Eland EA, Marks MA, Amendola KL: Perceptions of mentoring
relationships. J Vocat Behav 1997, 51:29–42.
17. Weng RH, Huang CY, Tsai WC, Chang LY, Lin SE, Lee MY: Exploring the
impact of mentoring functions on job satisfaction and organizational
commitment of new staff nurses. BMC Health Serv Res 2010, 10:240.
18. Population Council: Balanced Counseling Strategy Plus Trainer’s Guide Second
Edition, part of The Balanced Counseling Strategy Plus: A Toolkit for Family
Planning Service Providers Working in High STI/HIV Prevalence Settings.
Washington, DC: Population Council; 2011.
19. Warren CE, Mayhew SH, Vassall A, Kimani JK, Church K, Obure CD, du-Preez NF,
Abuya T, Mutemwa R, Colombini M, Birdthistle I, Askew I, Watts C: Study
protocol for the integra initiative to assess the benefits and costs of
integrating sexual and reproductive health and HIV services in Kenya and
Swaziland. BMC Public Health 2012, 12(1):973.
20. Ministry of Public Health and Sanitation & Ministry of Medical Services
(MoPHS, MOMS): National Guidelines for Prevention and Management of
Cervical, Breast and Prostate Cancers; Nairobi, Kenya. Nairobi, Kenya: Division
of Reprodcutive Health; 2012.
21. Government of Nepal: Ministry of Health and Population, National Health
Training Center. Implementation Guideline of Structured On-The-Job-Training
(OJT) for Postabortion Care (PAC) In Nepal. Nepal: Nepal Family Health
Program; 2007.
22. WHO: Recommendations for Clinical Mentoring to Support Scale-up of HIV
Care, Antiretroviral Therapy and Prevention in Resource-Constrained Settings.
20 Avenue Appia, 1211 Geneva 27, Switzerland: World Health Organization; 2005.
23. Philips M, Zachariah R, Venis S: Task shifting for antiretroviral
treatment delivery in sub-Saharan Africa: not a panacea. Lancet 2008,
371(9613):682–684.
24. Leppel K, Brucker E, Cochran J: The importance of job training to job
satisfaction of older workers. J Aging Soc Policy 2012, 24(1):62–76.
25. Coomber B, Barriball KL: Impact of job satisfaction components on intent
to leave and turnover for hospital-based nurses: a review of the research
literature. Int J Nurs Stud 2007, 44(2):297–314.
26. Castle NG, Engberg J, Anderson RA: Job satisfaction of nursing home
administrators and turnover. Med Care Res Rev 2007, 64(2):191–211.
27. Salt J, Cummings GG, Profetto-McGrath J: Increasing retention of new
graduate nurses: a syst emati c review of interventions by heal thcare
organizations. J Nurs Adm 2008, 38(6):287–296.
doi:10.1186/1472-6963-14-98
Cite this article as: Ndwiga et al.:Exploring experiences in peer
mentoring as a strategy for capacity building in sexual reproductive
health and HIV service integration in Kenya. BMC Health Services Research
2014 14:98.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Ndwiga et al. BMC Health Services Research 2014, 14:98 Page 11 of 11
http://www.biomedcentral.com/1472-6963/14/98
