Thanks to Clare Goodhart, Sarah Capewell, and Sarah Uwimbabazi for sharing their experience using the TRP to create their own courses, for their input into this report, and for sharing their photos and materials with us.

Background

Two courses were developed by a team from the UK for use in rural southwest Uganda, adapting the Training Resource Package for Family Planning. The pilot was done at Bwindi Community Hospital, a health care institution serving a population of 100,000. Level 1 training (Continuing Professional Development re Family Planning), involving five one-hour sessions, was offered to all staff, and 53 took part. The 30-hour Level 2 course (Family Planning Certificate) was run twice, and aimed to enable trainees to reach the standard of a certificate in family planning, equipping them to give detailed counselling about available methods and to undergo practical training. Level 2 was assessed by written exam, consultation skills, and participation in group work. Nineteen nurses and other clinical staff attended this more advanced training, and 17 successfully completed it. Since the training, screening for unmet need is becoming embedded across many hospital departments, which is a testimony to the improved confidence and knowledge gained through the training. The hospital’s community team are also undertaking outreach work to tackle barriers to male engagement in family planning.

The Training Team

Clare Goodhart of the UK National Health Service was awarded a Royal College of General Practice fellowship to develop a family planning initiative in Uganda. She worked with Sarah Capewell to develop a training module on family planning. In 2013, Sarah was working as a primary care doctor at Bwindi Community Hospital in Uganda for one year. She conducted a situational analysis of training needs and worked with Clare to create this two-tier ‘whole institution approach’ to family planning training, which has been evaluated by Dr Jonathan Graffy.

Adapting the TRP for Uganda

Clare found the Training Resources Package fairly late when searching for resources that could be used for training on the web. She realized that it would be useful in developing her own materials, but that she would have to cut down on the number of slides.

It was immediately more useful than any other resources we had found, not least because it was clearly in tune with the Global Handbook, MEC and counselling tools, etc. The main challenge was reducing the training to be deliverable in one week of training. – Clare Goodhart

In addition to providing basic information on contraceptive methods, the training focused on the importance of family planning to health in Uganda and worldwide, on the differences between myths about family planning and side effects of family planning, and on giving general health workers the skills to feel comfortable raising the topic of family planning during other health encounters.

Reducing the slides involved quite a lot of work, as it required looking through all the materials. In the end, the team used about a quarter of the slides and developed shorter versions of each of the presentations.

Clare mentioned that the facilitator documents were useful for ideas, and they deployed a range of other TRP methods, including role plays and case discussions. Additional resources and media beyond just presentations were needed to make the training more interactive and skills-building. They made films of IUD and implant insertions to supplement demonstrations with actual patients. Finally, their training also focused on training of trainers, but the TRP did not address that.

Both Level 1 and Level 2 modules were delivered as in-service training at Bwindi Community Hospital, with the goal of changing practice and service provision across the institution. The course was delivered in a highly interactive way. The course was run three times, with Sarah and a counterpart Ugandan practitioner co-facilitating the second and third sessions, as one of the objectives of the project had also been to train Ugandan trainers.

Training Evaluation Methodology

In addition to designing and conducting the training, the team also evaluated its impact on knowledge and confidence, using questionnaires about knowledge and attitudes, both before and after the training. The team did use some of the TRP assessment questions, but had to be selective in using them for pre- and post-course assessments and evaluation. They also recorded changes in institution and service delivery practices, and are trying to establish screening for unmet need for family planning in all the clinical departments of the hospital. The aim is that all patients having contact with the health facility will be offered the opportunity to address any unmet need for family planning while they are attending.

Gaps in the TRP

The team identified some gaps in TRP coverage. These included emergency contraception, sterilization, and natural family planning methods, although emergency contraception and lactational amenorrhoea modules are now available. (Note: An emergency contraception module is under development. There is now a module on the Standard Days Method). They also suggested that modules on youth-friendly services, cervical cancer screening, and STIs would be useful to them and would fit with a holistic view of service delivery.

Need for Supplementary Training Materials

Additional materials were needed to complement the training. They attempted to purchase MEC Wheels from WHO, but the wheels were difficult to obtain and expensive.¹ WHO did provide 30 copies of the Family Planning handbook and the team carried them out in their luggage. The handbooks were given as prizes to successful candidates. They also used the Ugandan version of the WHO flip-chart and a set of CycleBeads that Sarah had picked up at a conference. It was difficult to get other training resources. For example, sourcing affordable anatomical models was especially difficult. The team suggested that links to other inexpensive resources would be useful for the TRP website.

What’s Next

They will return to Uganda in Spring 2015 to re-run these courses and also to create and pilot a similar pre-service training for nursing students. The pace of the training for students would be slower, and they would want to be sure to link it closely to basic science and physiology coursework. Sarah stressed the importance of connecting the training with practical experience. Getting trainees to prepare and deliver health education talks was a useful part of the in-service training, and a similar exercise would be developed for nurse trainees. They could practice delivering health education talks to waiting mothers, mothers in the paediatric ward, and in hospital/clinic youth-friendly corners.

Suggestions for Further Development of TRP

Given the amount of work involved in cutting down the TRP resources to fit the week-long Level 2 course, Sarah and Clare felt a more concise version of each of the modules should be made available on the TRP website. If in-service training in family planning is to be made available to more health providers, shorter courses will be needed, and their experience showed that it was possible to train nurses and midwives to a good level of competence in one week. Meanwhile, the team would be happy to share the adapted TRP and other resources via Google Drive.

For training to have credibility, it is important to have rigorous assessment, and the team suggest that the TRP could make it easier to set this exam by developing a ‘question bank’ which could be drawn from the pre- and post-test questions provided in each module.

Follow-on practical training is also needed, and the team felt that it would be helpful for the TRP to include guidance on evaluating practical competencies. The TRP website could usefully include guidance on this practical training. For example, it might be useful to specify the number of IUD and implant insertions and removals which would need to be observed by a supervisor. An example of this sort of guidance is given for the UK Diploma of the Faculty of Sexual and Reproductive Health. 

Finally, Clare suggested that the TRP could help with the development and dissemination the Level 1 training modules. The goal of sensitising generic health care staff to the importance of family planning to other aspects of health is relevant to health care institutions worldwide. Recent studies suggest that an estimated 22% of maternal mortality and 20% of under-5 deaths can be traced back to unmet need for family planning. Family planning is also relevant to paediatric health services because of the link between large families and malnutrition, to adult inpatients because of the number of cases of septic abortion and fistula, and to obstetric ward staff, who should be providing family planning counselling to enable women to space their next pregnancy. This basic level of training can be contextualised by referring to country-specific data from local Demographic and Health Surveys.

Lessons Learned & Going Forward

Despite encouragement from the training team, pre-learning didn’t really happen. Staff was encouraged to take the online HEAT courses developed for the Ethiopian context or courses on the Global Health eLearning Center, but the majority did not, possibly because they didn’t see it as part of the agreement to do prior e-learning during their own free time.

The communication skills and counselling training aspect of the course was very important, so it would not be possible to replace the face-to-face training completely with eLearning.

Would there be a possibility of creating a recognised certificate/qualification in Family Planning? Clare said that providing certificates did motivate people, but it would be better if they were nationally or internationally accredited.

One of the biggest challenges in Uganda is the rising prevalence of teenage pregnancies. In an attempt to address this, the Bwindi team are nurturing a group of Pastoral Lead Teachers from over 60 local schools to improve the provision of sex education. An early project will be the rolling out of ‘Sugar Daddy Awareness Lessons,’ which was first piloted in Kenya using UNICEF materials.

The team in Uganda were also considering proposing a ‘Family Friendly’ accreditation for institutions that meet family planning standards. This could perhaps be along the lines of the UNICEF Baby-Friendly Hospital Initiative, for which hospitals must take steps to actively support breastfeeding.²

Anyone who shares an interest in any of the developments above is welcome to be in touch: clare.goodhart@nhs.net.

<sup>1. Copies of the MEC Wheel can be ordered from WHO at a cost of $72 for 20 wheels or 43 CHF to developing countries. See the WHO website for ordering information. ↩
2. See the Baby-Friendly Hospital Initiative for additional information. ↩</sup>