Training Involves Many Factors

Assessing needs, evaluating the outcomes and maintaining skills are among important considerations.

Network: Fall 1998, Vol. 19, No. 1

The effectiveness of training to improve provider practices depends upon many factors: who is trained and where, what providers are learning and how the information is taught, whether training is reinforced, and how training results are measured.

Training should begin with a thorough understanding of providers' abilities, needs and the settings in which they work. How skills acquired during training can be sustained is important to consider during this early planning.

What are the community's reproductive health needs? What knowledge, skills, experience and attitudes do providers already have? What do providers further need and want? Who should receive training? Answering these questions, formally called a "needs assessment," is essential.

Needs assessments can identify obstacles to successful training, which may be as simple as a lack of adequate supplies or facilities. Training providers to administer a certain contraceptive method, for example, is useless if the contraceptives themselves are unavailable.

Assessing existing provider knowledge and skills is also vital. "An important aspect of training is getting providers to unlearn wrong information, especially when it can lead to faulty practices that can harm patients," says Dr. Pouru Bhiwandi, an obstetrician and gynecologist in private practice in the United States and former FHI medical director and director of international programs. "Often, this must be done before teaching providers what is right to do." For example, she says, incorrect technique for assuring sterile conditions when inserting an IUD could expose the client to infection, which could lead to pelvic inflammatory disease.

Whom to train, and where?

Training may involve a few designated individuals, a team or an entire staff. One model developed by New York-based AVSC International (AVSC) emphasizes the value of training everyone who works at the same location. "Ideally, everyone at the site -- including gardeners, secretaries and cleaners -- is involved in evaluating site performance" during the needs assessment planning stage, says Dr. Pamela Lynam, manager of AVSC's Reproductive Health Linkages Program. "Teams make recommendations for improvement and, because they made the suggestions, they usually carry them out."

This way of motivating staff members to identify their own training needs is called the Client-Oriented, Provider-Efficient (COPE) approach. Each staff member completes an assessment questionnaire. "We believe that COPE is absolutely key in motivating people to want to improve services," she says.

Under the COPE system, training is usually done at the work site rather than taking staff to another location. There are advantages, however, to training away from the work place and its interruptions. "Medical professionals who are offered the chance to leave work settings filled with distractions and to meet with their peers for a short period of intensive learning, ideally in settings that are convenient and pleasant, tend to feel that they are participating in a cadre of excellence, that they are on the cutting edge," says Robert Rice, a training manager at FHI. "This is a powerful incentive for them to make sacrifices required to update their skills."

Dr. Lynam agrees that this approach, called centralized training, can be useful under certain circumstances, such as when a new contraceptive method is introduced and few or no local providers have experience with it. "Centralized training, however, is expensive, often excludes many key providers while training some people who will not use their new skills, and does not reflect the reality of the local service delivery site," she says. "Providers who attend such centralized training events tend to return to their home sites only to find that no one else knows about the training and equipment. Drugs and supplies used or promoted during training may not be available. As a result, these newly-trained providers often just give up."

Training at the site allows specialized training for select people, while giving general training to orient everyone.¹ "As a result of this whole-site training, pharmacists order the right drugs, gatekeepers know about the new services, receptionists are informed and supportive," says Dr. Lynam.

Team training is another approach. If several professionals from a service delivery site are trained instead of only one or two, the absence of any one of those people from the site will have less impact on services. In addition, if several people from a site are trained, prospects are better for spreading the new information to others at the work site.

Training people in related jobs to provide family planning services can be a useful strategy. When family planning training was given in India to those who practice traditional methods of healing, such as the use of herbs, contraceptive use increased among the rural women who were served by the trained traditional healers.²

People with a variety of health-related experiences often "are responsible, respected members of the community and, as such, can influence expectations about health behavior," says Dr. Sharon Rudy of INTRAH, a reproductive health training program affiliated with the University of North Carolina School of Medicine in the U.S. INTRAH has worked extensively in developing countries to improve performance of family planning providers. "We have had a lot of success working with a variety of people -- ranging from community-based distribution workers to midwives and traditional birth attendants."

Even people who simply use contraception can play an important role. In Sri Lanka, women who had used IUDs and oral contraceptives successfully were trained to help midwives motivate others to use these methods.³

The process

The process of training may be as important as the content. "Unless you pay equal attention to process, content is almost irrelevant," says INTRAH's Dr. Rudy. "The goal of the learning situation is to ensure that a particular skill will be performed, but many people who design instructional materials and do training are products of educational systems that rely on rote memorization of information. So there is a tendency to focus on knowledge as a learning goal, rather than changes in provider behavior."

Training techniques vary, but those considered most effective generally recognize that adults learn best when they build on personal experience. Interactive approaches, such as role plays, case studies and small group discussions, are other ways to make training more dynamic. Using anatomic models and coaching to teach clinical procedures, and regularly assessing how well trainees perform a skill, are other techniques that seem to be successful.

"Because the interactive style of training is unfamiliar to most medical professionals, they feel silly at first doing it," says Dr. Irina Yacobson, an assistant medical director at FHI. "But after a couple of hours of participatory training, they like it because it is fun. When I am doing technical training, I break presentations into 15-minute sessions, then reinforce what I've presented with a game or case study or small group discussion. Then I give another session of technical information."

Dr. Erwin Conrado Curán Padilla, a Guatemalan obstetrician and gynecologist who conducts training, recently participated in an FHI-sponsored workshop to help trainers enhance their skills. After making a presentation about IUDs that was designed to include interaction with the audience, he commented that "not everyone shared my ideas. But I liked that. I also liked knowing that lively discussion would lessen misunderstanding of what I was teaching."

Training with an interactive approach is very useful in helping providers to evaluate important personal viewpoints or values, both a client's and the provider's own, a particularly important aspect of effective counseling. Called "values clarification," this exercise was part of FHI provider training in Senegal, where research showed that services for adolescent clients were being compromised by stigmatization and discrimination by some providers who did not believe young people should receive contraceptives.

"In this circumstance, if providers do not change their approach to clients, their own values and viewpoints become barriers to service," says Dr. Yacobson. A conventional way to train people for this problem might include more technical information, justifying why contraception for adolescents is important. In the Senegal training, however, FHI led providers through a values clarification exercise, showing participants how their personal opinions could affect counseling, and encouraged them to modify personal attitudes that may hinder services.

Illustrating how people have different values can be enlightening, she says. "Often providers think they know each other well. After all, they have worked and even socialized together. Yet during values clarification exercises, they discover that there are many things they do not know about each other. Still, they like each other and finally realize that, while they might disagree, each is entitled to his or her own values and views."

The training process can be modified for self-study. JHPIEGO Corp., an international reproductive health training organization affiliated with Johns Hopkins University in the U.S., has developed a self-paced, on-the-job learning package, says Dr. Rick Sullivan, director of JHPIEGO's Learning and Performance Support office. In field tests in Zimbabwe and Kenya, this form of self-study, working with a job coach, has been well received, he says.

Computer technology, adds Dr. Sullivan, may offer new ways to provide self-education, especially at large work sites. Computers allow participants to control the pace and flow of their learning. In a field test in rural Zimbabwe, "the response from people who had never seen a computer before was very positive," he says. "Like training at the job site, computer-assisted learning places the power to learn in the hands of the trainee. Computer technology also frees trainers from making rote presentations, giving them more time to engage in valuable activities such as doing role plays or training on models."

Clinical procedures training

When training providers to perform certain clinical procedures, use of anatomic models is helpful. For example, practicing Norplant insertions on arm models promotes consistent, well-placed insertions and helps prevent difficult removals. After adequate practice, performing these procedures with supervision on clients is an ideal part of training.

The same applies to IUD insertions. "At FHI, we usually do a day of training using the pelvic model," says Dr. Yacobson, "with a provider inserting the device while talking to the model, anticipating that in real life this would be a woman who is hearing unfamiliar sounds made by metal tools, perhaps suggesting a major surgical procedure is about to take place."

In a study in Thailand, 150 midwives received IUD insertion training using a pelvic model. They became competent to perform the procedure more quickly than 150 midwives receiving traditional IUD insertion training. For the first group of midwives -- who received clinical guidelines, a week of classroom training using the pelvic model and a week of practice on patients -- the mean number of insertions to achieve competency was 1.6, compared with 6.5 for those midwives who received two weeks of classroom training with no model and four weeks of clinical practice.⁴

Similarly, a study in Indonesia showed that 151 physicians, nurses and midwives receiving model arm training for Norplant insertion achieved competency in insertion procedures sooner than 151 such professionals not receiving model arm training. Furthermore, more of the participants trained with the model arm achieved removal competency than did participants with no model arm training.⁵

Evaluating training

It is difficult to evaluate how training improves provider practices in terms of measuring client satisfaction, method continuation, and similar goals. Some contraceptive use and service delivery data are only available years after training has taken place. Also, training evaluations can be very costly.

Instead, the most common means of evaluating training include measuring the participants' skills before and during training; asking them whether they were satisfied with workshops; and assessing their skills during actual performance, through client interviews, observations and other ways.

However, greater acceptance of contraceptive methods due to provider training has been demonstrated in a number of studies and settings. In Uganda, after INTRAH and the Ministry of Health of Uganda trained 136 nurse's aides from nine districts to counsel about the benefits of family planning, the number of new clients rose dramatically. New acceptors of oral contraceptives, condoms, and depot-medroxyprogesterone acetate (DMPA) rose in 34 health clinics staffed by trained nurses' aides.⁶

In a training program introduced by the Egyptian Ministry of Health, development of family planning nurses' counseling skills was stressed. A study sponsored by FHI in collaboration with the National Population Council found that this improved training was associated with positive changes in family planning knowledge, attitudes, and behavior among women attending study clinics. Favorable attitudes about oral contraceptives and condoms also became more common and, in one governate, IUD use increased.⁷

Also in Egypt, training providers on IUD insertion and counseling was so successful that the IUD became the most prevalent method in the country. In contrast, failure to emphasize counseling and education during the promotion of oral contraceptives during the 1960s and 1970s resulted in considerable noncompliance.⁸

In a 1992 Nigerian study, three days of counseling training for certified nurses significantly improved the quality of care they provided compared with certified nurses who did not receive such training. Client return visits, highly correlated with continuation rates, also increased.⁹

Maintaining skills

Training must be repeated to produce lasting changes in behavior. "We often want to train too many people too quickly in too many things simultaneously," says Dr. Roberto Rivera, FHI corporate director of international medical affairs. "But most educational goals have to be achieved through consecutive steps. The truth is that training not only takes resources and time, but requires follow-up, assessment and retraining -- it is a continuing cycle."

Refresher courses after several months are valuable, adds FHI's Dr. Yacobson. "They allow providers to discuss how their new knowledge or skills worked in practice, identify what problems arose, and correct misinformation."

In a study in India, retraining workshops for medical and paramedical providers working with IUD and oral contraceptive users contributed to improved continuation rates. The retraining addressed counseling and motivational skills, management of side effects and follow-up care.¹⁰

Unfortunately, training often occurs only once. Thus, it is imperative that newly trained providers have colleagues who can supervise their skills.

AVSC has found that its "whole-site" training approach that includes supervisors helps programs sustain improvements. Says Maj-Britt Dohlie, AVSC program manager of quality improvement: "Supervisors not only support newly trained staff as they apply their new skills and knowledge. They also are in an excellent position to determine later whether training has met expectations and remains of good quality."

Supervision of providers trained to perform clinical procedures such as IUD or Norplant insertions and removals is especially important. Yet a study in Senegal of women's experiences with Norplant removal showed that, regardless of the type of training given, few providers said they had removed many implants under supervision, generally recognized as more difficult than insertion.¹¹ Using newly acquired skills is important. In a Kenyan study, skill retention depended more on providers' use of skills than on time elapsed since training.¹²

"In terms of sustaining skills, it is also essential that you have someone locally who can understand how to deliver services with limited resources," says Dr. Bhiwandi, the former FHI medical director. Dr. Rivera agrees. "It is absolutely necessary for an organization like ours to help support local institutions in their efforts to create their own training structures," he says. "An international training organization will only be successful when it has created local resources and structures to support and continue the training we do. There is no other way."

-- Kim Best

References

1. Bradley J, Lynam PF, Dwyer JC, et al. Whole-site Training: A New Approach to the Organization of Training, AVSC Working Paper No. 11. New York: AVSC International, 1998.
2. Kambo IP, Gupta RN, Kundu AS, et al. Use of traditional medical practitioners to deliver family planning services in Uttar Pradesh. Stud Fam Plann 1994;25(1):32-40.
3. Family Planning Association of Sri Lanka, University Research Corporation. Satisfied users as family planning motivators for pills and IUDs. Operations Research Family Planning Database Project Summaries. (New York: Population Council, 1993)SRI-04.
4. Limpaphayom K, Ajello C, Reinprayoon D, et al. The effectiveness of model-based training in accelerating IUD skill acquisition. A study of midwives in Thailand. Br J Fam Plann 1997; 23(2):58-61.
5. Bongiovanni A, Gaffikin L, Affandi B, et al. Indonesia Field Assessment: Subdermal Implant Training Model. Baltimore: JHPIEGO Corp., 1996.
6. Knauff L, Muhuhu P, Yumkella F. Improving service access in the Mountains of the Moon. Presentation at the 122nd Annual Meeting of the American Public Health Association, Washington, DC, October 30-November 3, 1994.
7. Halawa M, Bashay MF, Eggleston E, et al. Assessing the impact of a family planning nurse training program in Egypt. Popul Res Pol Rev 1995;14(4):395-409.
8. Hassan EO, Fathalla MF. Broadening contraceptive choice: lessons from Egypt. Presentation at the Symposium on Family, Gender, and Population Policy: International Debates and Middle Eastern Realities, Cairo, Egypt, February 7-9, 1994.
9. Kim Y-M, Rimon J, Winnard K, et al. Improving the quality of service delivery in Nigeria. Stud Fam Plann 1992;23(2):118-27.
10. Indian Council of Medical Research Task Force on IUD and Hormonal Contraceptives. Improved utilization of spacing methods -- intrauterine devices (IUDs) and low-dose combined oral contraceptives (OCs) -- through re-orientation training for improving quality of services. Contraception 1994;50(3):215-28.
11. Tolley E, Nare C. Women's experiences with Norplant removal in four clinics in Dakar. Unpublished paper. Family Health International, 1997.
12. Valadez JJ, Transgrud R, Smith T, et al. Assessing the Post-training Family Planning Service Delivery Skills of Clinical Providers in Kenya. Baltimore: JHPIEGO Corp., 1997.

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