Article Text

Education and Ebola: initiating the cascade of emergency healthcare training
  1. Will Eardley1,2,
  2. D Bowley3,
  3. P Hunt4,
  4. J Round5,
  5. N Tarmey6 and
  6. A Williams7
  1. 1Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, UK
  2. 2Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
  3. 3Royal Centre for Defence Medicine, Birmingham, UK
  4. 4Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
  5. 5Department of Anaesthetics, James Cook University Hospital, Middlesbrough, UK
  6. 6Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth, UK
  7. 7Department of Cardiology, Royal Gwent Hospital, Newport, UK
  1. Correspondence to Lt Col Will Eardley, Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough TS4 3BW, UK; willeardley{at}


In response to the 2014 Ebola virus outbreak in West Africa, the UK deployed a Joint Inter-Agency Task Force to Sierra Leone. As well as constructing Ebola treatment units, the force supported a rapidly upscaled mass programme of training for host nation healthcare workers in basic knowledge of Ebola and personal protective equipment. A bespoke training course was developed in collaboration with the WHO and other partners over a period of 2 weeks, taught to 119 trainers the following week, and then cascaded to over 4000 Ebola workers over the following month. This article describes curriculum design, content delivery and assessment of this unique Training The Trainers course delivered in austere circumstances. Key learning points are highlighted and supplementary material is provided to inform future deployed clinical education initiatives.


Statistics from

Key messages

  • Contingency deployments characterize both current and future deployments of Defence Medical Services staff.

  • These operations such as the recent deployment to Sierra Leone will have increasing shared leadership with civilian agencies.

  • A key element of such missions will involve interagency working and educational initiatives.

  • This paper illustrates the educational elements of the recent deployment to Sierra Leone and provides an educational framework for future similar operations.


In March 2014, an outbreak of Ebola virus disease (EVD) occurred in West Africa. In order to support the Government and the overstretched health infrastructure of Sierra Leone, the UK deployed a Joint Inter-Agency Taskforce (JIATF) to the country in September 2014. This combined military and civilian body, under the aegis of the Department for International Development (DFID), incorporated a cohort of 63 UK military medical personnel tasked to train local healthcare workers, hygienists and military staff. These UK personnel were neither doctors nor nurses but soldiers trained in battlefield medicine and basic primary care. They would be working alongside Sierra Leonean nurses, soldiers and university staff in order to generate a multidisciplinary, multinational and multilingual healthcare workforce to aid the response to the Ebola crisis. A period of only 2 weeks was available to design and prepare the course, with one further week to train a cohort of approximately 120 UK and Sierra Leonean trainers. Over the following month, these new trainers were to train over 4000 personnel in basic knowledge of EVD and the safe use of personal protective equipment (PPE).

To prepare the trainers, a training the trainers (TTT) package was developed so UK personnel and Sierra Leonean volunteers could achieve: basic understanding of EVD and Infection Control and Prevention (IPC) principles, practical awareness of generic PPE skills; and instructional capability in the subject matter. In total, 25 training teams each consisting of two UK personnel and two Sierra Leoneans were required to meet the projected teaching target.

The rapid deployment and challenging timelines characterise the new era of contingency deployment. As part of the humanitarian scope of future operations and in order to build host nation resilience, it will be beholden on the medical command chain and clinicians to be able to rapidly upscale healthcare teaching programmes.

Within this work we provide the first evaluation of a deployed humanitarian teaching programme, including a complete ‘off the shelf’package of materials that may be used by future deploying medical personnel.

TTT course

Curriculum design

Six consultant clinicians of the deployed UK taskforce formed a clinical faculty from which curriculum design and training packages could be delivered in conjunction with various civilian partners. There was a need to combine the planned curriculum—that joined vision of the civilian and military command chain with the delivered curriculum—the actual factual content in order to achieve the overall aim. Integration with stakeholders was therefore essential in order to coordinate these two elements and produce a mutually acceptable teaching package.1

In Sierra Leone, the WHO was already delivering a programme of training courses for EVD workers and recognition must be given to them for the source materials of this report. However, there was a lack of suitable trainers available to the WHO and demand for these courses greatly exceeded their capacity. The clinical faculty engaged with WHO staff, non-governmental organisations (NGOs) and other host nation stakeholders to assimilate and refine existing resources to deliver a teaching solution that could be scaled and administered rapidly. Also it would need to endure beyond international aid worker participation, thereby building in resilience and durability for any possible future outbreaks. As part of the scoping process for curriculum design, members of the clinical faculty and nursing staff from the Role 2 Medical Facility participated, in rotation, in the 3-day WHO healthcare training package. This participation encouraged collaboration and enabled early networks to be formed, which would be vital to the later coordination and corporate acceptance of the TTT package.

Attendance at the WHO training, as well as benchmarking the individuals and enabling networking, also afforded the future instructors opportunities to assimilate the key skills and knowledge base required to provide subsequent EVD specific healthcare teaching.

The key domains of the curriculum that were reinforced by the WHO training included:

  • EVD theory

  • PPE theory

  • PPE practical training.

Early stakeholder engagement was crucial in the latter domain due to the emotive issues associated with PPE donning and doffing drills. Working in collaboration with the WHO, the faculty adopted elements of the existing source material to develop a bespoke teaching package. Despite being undertaken in a national crisis, the curriculum was designed to ensure that content delivery and evaluation processes were properly considered. A locally applicable educational solution was needed: although English is officially the national language, most delegates were more fluent in Krio (the lingua franca of Sierra Leone), and some delegates spoke mainly tribal languages. Incorporation of host nation trainers was therefore essential for delivery and educational resilience.

Although the training was designed as a participatory workshop, modelling the curriculum required a prescriptive approach, with objectives clearly defined by the task intent. In order to keep healthcare workers safe and maximise their impact on reducing disease spread, the training required that core knowledge should be rapidly assimilated and delegates undergo drilling in generic PPE skills and principles. It may be considered that prescription restricts what is delivered in this predominantly teacher-centred experience.

This ‘old-fashioned’ approach was accepted, however, due to the time constraints imposed by an exponential rise in EVD cases that required rapid delivery of staff with basic training in Ebola-specific IPC practices in order to staff the emerging treatment facilities.

Course structure

The TTT course was a 4-day event, the first 3 days of which comprised generic information acquisition (basic EVD knowledge and PPE drills). This 3-day core element was the course that the UK and Sierra Leonean trainers would then go on and deliver themselves to local healthcare workers across the country.

The fourth day of the TTT package was a specific candidate evaluation and consolidation day during which assessment of knowledge and PPE drills took place. The clinical faculty constructed lesson plans and daily course timetables to provide an ‘off the shelf’ fully contained teaching package so future trainers would require only one document from which to run the course (see online supplementary materials).

Teaching equipment

Use of modern standard electronic audiovisual equipment was not possible due to the austere teaching conditions (no electricity in the venues). Course materials were instead printed out at size A0 (84×119 cm) on plastic sheets collated into teaching packs (Figure 1). An efficient means to display these was needed and easels were sourced and constructed by local craftsmen.

Figure 1

Delivery of WHO approved teaching material with locally constructed materials.

To equip 25 independent training teams, a total of 2250 pages of A0 were printed and bundled into six lesson packs to be hung onto the 25 easels.

Of note, this cost in excess of $100 000. However, the significant capital cost was balanced against the potential costs of ongoing power generation and maintenance needed to sustain alternative Information Technology resources. PPE was also required and the scaling of this, an example of the necessary logistics, is available with the online supplementary materials provided.

Course evaluation

Conducting TTT courses during an Ebola crisis requires proper validation and assessment, as with any other training course. Assuring candidate competency and improvement in knowledge and confidence is arguably even more important under these circumstances. Healthcare workers are known to be at particular risk of contracting EVD, and a single breach of PPE can lead to infection. The 4-day TTT package was attended by 63 UK military medical personnel and 56 Sierra Leonean healthcare workers, university and military staff. These candidates were formatively assessed on their generic ability to instruct, as well as their enthusiasm and ability to work alongside other healthcare workers, including those with different nationalities and backgrounds. In addition to summative assessment of candidate enthusiasm, application and suitability for independent instructor status, the clinical faculty assessed candidates’ precourse and postcourse knowledge and confidence using a visual analogue scale (VAS) (see online supplementary materials). In order to prevent instructor bias from influencing the results of the evaluation, forms were analysed and the data collected by members of the clinical faculty not directly involved in delivery of the TTT package. Parametric data were analysed by a two-tailed independent samples t test (Table 1).

Table 1

Characteristics and self-reporting results for all delegates (n=119)

Post hoc analysis of the data demonstrated an ability to detect a statistically significant difference of an effect size of two-point change in VAS powered to 80% (α=0.05, two-tail) for self-reported candidate knowledge and confidence in teaching about EVD.

First, change in factual knowledge about EVD following course participation demonstrated a median change on the VAS of 4.0 by all delegates (p<0.001). Second, change in confidence in teaching about EVD by all delegates demonstrated a median change on the VAS of 5.0 for all delegates (p<0.001) (Figure 2). The course therefore provided to a level of high statistical significance, an increase in EVD knowledge and teaching confidence of UK and Sierra Leone (SL) student trainers. Finally, the aim of producing an effective cohort of UK and SL trainers was successfully achieved. At the time of writing (6 weeks after the conclusion of our TTT course), over 4000 Ebola workers have been trained on the cascaded courses. A full evaluation of their training and subsequent work is underway and will be the subject of a future report.

Figure 2

Self-reported responses for precourse and postcourse visual analogue scale: All delegates (n=119).


After a decade or more of combat support medical care in the Middle East, the Ebola crisis reintroduced the UK Defence Medical Services to contingency operations. Having accounted for small outbreaks in Sub-Saharan Africa since its discovery in 1976, in 2014 the profile of EVD radically changed as it became a global concern.2 Owing to existing healthcare course provision in Sierra Leone failing to keep pace with demand on a backdrop of a rising death rate, British military doctors and nurses collaborated with the WHO to rapidly design and deliver a TTT package, in order to facilitate mass-scale training.

This course was established in a time-critical manner, on the background of an exponential rise in cases of EVD in Sierra Leone. The clinical faculty found themselves working in ‘the shadow of the curve’; expectations were high and pressure to deliver on time was considerable.3 Critical to success was consultation and collaborative planning. These are known to be essential to stakeholders approaching such a time pressured, massed teaching task.4 Utilising this Healthcare Action Team approach to develop a collaborative agenda and engage key stakeholders, we rapidly incorporated WHO course materials into a bespoke TTT package.

This mission and the training programme described are unique. This was a Joint Inter-agency Task Force operation, the first time that deployment of a British Army enabling brigade has occurred under joint leadership with DFID. Relationships between civilian aid organisations and military forces are often characterised by strain, predominantly borne out of concern for neutrality and staff safety in the postconflict stage of war.5 In the setting of this EVD outbreak, however, such negative postures were not encountered. It was vital that this new atmosphere of cohesion was not threatened by the introduction of the TTT course. Transparency and early stakeholder engagement were central, which was one of the key learning points of this experience.

Conscious of the cultural setting of the outbreak, it was critical that Sierra Leonean staff were fully integrated in the training; not only as some of the future students would potentially speak little English, but also to enable authoritative debunking of some of the prevalent myths surrounding the disease.

Rapid up scaling of training such as that featured in the recent Ebola crisis is already a feature of medical education in Africa. A ‘flooding strategy’ has been used by the Ethiopian Government to address a serious deficiency in its healthcare workers.6 Locally based, workshop training such ours parallels initiatives already in place throughout the continent. The Medical Education Partnership Initiative (MEPI) established by the USA government is one such example. Community-based education (CBE) under the MEPI umbrella helps medical students to approach health problems in their community as well as preparing them to perform effectively within their national health systems.7 CBE has been shown to improve practical skills of healthcare workers and also to instil the social mission of medical training.8 Rapid community intervention and education therefore has provenance in the regional healthcare framework.

Despite being produced at a time of crisis and while having parallels with on-going healthcare initiatives throughout Africa, there are of course limitations with such rudimentary education provision. For instance, personnel allocated to be trainers were not volunteers, nor were they selected for their attributes as instructors. UK personnel deployed at short notice to a developing tropical nation also resulted in challenging medical force protection issues. This was not a standard PowerPoint-based course delivered in a purpose built-learning environment: heat, humidity and lack of acclimatisation all had to be contended with by the incoming training teams.

These conditions reinforce the importance of an ‘off the shelf’ inclusive package—the time available to the newly arrived trainers was maximised in information acquisition and contact with subject matter experts, not in designing their own course. Training was prescriptive: effective information transfer, its assimilation and utility for onward teaching of both EVD background knowledge and PPE drills were safety critical. Such teacher-centred approaches to learning may draw criticism from educational purists.9 This criticism may be countered, however, in the context of assisting a population in the grip of a virus with a significant case death rate. At the time of writing, Sierra Leone had the highest total number of reported cases of the three intense transmission countries (Sierra Leone, Guinea and Liberia) with 7897 cases reported. Case death for each nation is dependent on the vagaries of the reporting system although most recent figures from the WHO show that overall a case death in those patients with a definitive outcome across all three countries is 71%.10

Limitations notwithstanding, we have shown that it is achievable, in the midst of an on-going healthcare crisis in a country with significant infrastructure challenges, to provide a rapid response to an identifiable educational need. Analysis of the feedback reveals a significant and realistic change in both candidate knowledge and, most importantly, confidence in teaching the safety critical PPE drills: unique data from the first evaluation of a humanitarian TTT package.

Early stakeholder involvement with NGO and host nation clinicians is key and enables deployed trainers to influence disease progression ahead of the disease curve. This collaborative model highlights the rapid progress that can be achieved with limited resources and will influence future humanitarian missions: educational requirements should be addressed alongside infrastructural support, both to save lives and to provide resilience for future healthcare crises.


We have shown that, by working with local and international partners, targeted training can be cascaded quickly and effectively as a key part of a multiagency response to a healthcare emergency.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:


  • Contributors All authors contributed equally to the training the trainers course and the manuscript preparation. WE is the guarantor.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.