Use of a hybrid digital training approach for hormonal IUD providers in Nigeria: results from a mixed method study.

BACKGROUND: In Nigeria, in-service trainings for new family planning (FP) methods have typically been conducted using a combination of classroom-based learning, skills labs, and supervised practicums. This mixed-methods study evaluated the feasibility, acceptability, provider competency, and costs associated with a hybrid digital and in-person training model for the hormonal intrauterine device (IUD). METHODS: The study was conducted in Enugu, Kano, and Oyo states, Nigeria, and enrolled FP providers previously trained on non-hormonal IUDs. Participants completed a digital didactic training, an in-person model-based practicum with an Objective Structured Clinical Examination (OSCE), followed by supervised provision of service to clients. Provider knowledge gains and clinical competency were assessed and described descriptively. Data on the feasibility, acceptability, and scalability of the approach were gathered from participating providers, clinical supervisors, and key stakeholders. Training costs were captured using an activity-based approach and used to calculate a cost per provider trained. All analyses were descriptive. RESULTS: Sixty-two providers took the hybrid digital training, of whom 60 (91%) were included in the study (n = 36 from public sector, n = 15 from private sector, and n = 9 both public/private). The average knowledge score increased from 62 to 86% pre- and post-training. Clinical competency was overall very high (mean: 94%), and all providers achieved certification. Providers liked that the digital training could be done at the time/place of their choosing (84%), was self-paced (79%), and reduced risk of COVID-19 exposure (75%). Clinical supervisors and Ministry of Health stakeholders also had positive impressions of the training and its scalability. The hybrid training package cost $316 per provider trained. CONCLUSIONS: We found that a hybrid digital training approach to hormonal IUD service provision in Nigeria was acceptable and feasible. Providers demonstrated increases in knowledge following the training and achieved high levels of clinical competency. Both providers and clinical supervisors felt that the digital training content was of high quality and an acceptable (sometimes preferable) alternative to classroom-based, in-person training. This study provided insights into a hybrid digital training model for a long-acting contraceptive, relevant to scale-up in Nigeria and similar settings.

Uptake of reproductive, maternal and child health services during the first year of the COVID-19 pandemic in Uganda: A mixed methods study.

Use of reproductive health (RH), maternal, newborn and child health (MNCH) services in Uganda is suboptimal. Reasons for this are complex; however, service-delivery factors such as availability, quality, staffing, and supplies, contribute substantially to low uptake. The COVID-19 pandemic threatened to exacerbate existing challenges to delivery and use of high-quality RH and MNCH services. We conducted a mixed methods study, combining secondary analysis of routine electronic health management information system (eHMIS) data with exploratory key informant interviews (KII) to examine changes in health service uptake over the course of the pandemic and to understand service delivery adaptations implemented in response. We analyzed eHMIS data for four services (family planning, facility-based deliveries, antenatal visits, and immunization for children by one year), comparing them across four time periods: pre-COVID-19, partial lockdown, total lockdown and post lockdown. Additionally, KIIs were used to document adaptations made for continuity of health services. Use of services declined substantially during total lockdown; however, rebounded quickly to earlier observed levels, during the post lockdown for all four services, especially for immunization for children by one year. KIIs identified several health services delivery adaptations. At the community level, these included: community outreaches, training some mothers as community liaisons to encourage others to seek health services, and support from local leaders to create call centers to facilitate clients transport during travel restrictions. Health facilities creatively used space to accommodate social distancing and shifted providers' roles. District leadership reassigned health workers to facilities closest to their homes, provided vehicle passes to staff, and ambulances to transport pregnant women in critical need. WhatsApp groups facilitated communication at district level and enabled redistribution of supplies. Ministry of Health produced critical guidelines for continuity of health services. Implementing partners provided and redistributed commodities and personal protective equipment, and provided technical support, training and transport.

Use of Objective Structured Clinical Examination (OSCE) in a hybrid digital / in-person training for hormonal IUD in Nigeria: findings and applications of the approach.

Background: The hormonal intrauterine device, a long-acting reversible contraceptive method, is being introduced to pilot sites in the private and public sector in Nigeria by the Nigerian Federal Ministry of Health since 2019. To inform training of health care providers, a study was conducted on a hybrid digital and in-person training which utilized Objective Structured Clinical Examination (OSCE) to assess competency of provider trainees. This study represents one of few documented experiences using OSCE to assess the effectiveness of a digital training. Methods: From September - October 2021, in Enugu, Kano and Oyo states of Nigeria, 62 health care providers from public and private sector health facilities were trained in hormonal IUD service provision using a hybrid digital / in-person training approach. Providers, who were skilled in provision of copper IUD, underwent a didactic component using digital modules, followed by an in-person practicum, and finally supervised service provision in the provider trainee's workplace. Skills were assessed using OSCE during the one-day practicum. Results: Use of the OSCE to assess skills provided valuable information to study team. The performance of provider trainees was high (average 94% correct completion of steps in the OSCE). Conclusions: OSCE was used as a research methodology as part of this pilot study; to date, OSCE has not been integrated into the training approach to be scaled up by FMOH. Uniformly high performance of provider trainees was seen on the OSCE, unsurprising since provider trainees were experienced in providing copper IUD. If and when training is rolled out to providers inexperienced with copper IUD, OSCE may have a more important role to assess skills before service provision. The role of OSCE in design of hybrid digital / in-person training approaches should be further explored in rollout of hormonal IUD and other contraceptive technologies.

Women's Experiences With Family Planning Under COVID-19: A Cross-Sectional, Interactive Voice Response Survey in Malawi, Nepal, Niger, and Uganda.

INTRODUCTION: We conducted an assessment in Malawi, Nepal, Niger, and Uganda to document access-related reasons for not using contraceptive methods during the COVID-19 pandemic that led to unintended pregnancies, describe use of modern contraception among women in potential need of contraception compared to before the pandemic, examine method choice, and describe barriers to contraceptive access and use. METHODS: Between December 2020 and May 2021, we conducted an opt-in phone survey with 21,692 women, followed by an outbound survey with 5,124 women who used modern nonpermanent contraceptive methods or who did not want to get pregnant within 2 years but were not using a modern contraceptive method. The surveys examined current behaviors and documented behaviors before the pandemic retrospectively. We used multivariable logistic regression models to examine factors associated with contraceptive use dynamics during COVID-19. RESULTS: Pregnant women surveyed reported that the pandemic had affected their ability to delay or avoid getting pregnant, ranging from 27% in Nepal to 44% in Uganda. The percentage of respondents to the outbound survey using modern contraception decreased during the pandemic in all countries except Niger. Fear of COVID-19 infection was associated with discontinuing modern contraception in Malawi and with not adopting a modern method among nonusers in Niger. Over 79% of surveyed users were using their preferred method. Among nonusers who tried obtaining a method, reasons for nonuse included unavailability of the preferred method or of providers and lack of money; nonusers who wanted a method but did not try to obtain one cited fear of COVID-19 infection. CONCLUSION: We found evidence of surveyed women attributing unintended pregnancies to the pandemic and examples of constraints to contraceptive access and use on the supply and demand side. The effects of the pandemic must be interpreted within the local contraceptive, health system, and epidemiological context.