“For me, cue-card if I have any quick thing to check …at my convenience I check the phone… For a critical problem where you don’t have an answer, you move away and check the phone.” – Distance learning program participant during a focus group discussion
According to the 2010/2011 Nigeria Baseline Household Survey for the Urban Reproductive Health Initiative, an average of 27.9% of married women were using modern family planning (FP) methods in the cities of Abuja, Ibadan, Ilorin and Kaduna. However, the 2010/2011 Baseline Facility Survey showed that service providers were restricting the use of many FP methods for reasons that included age, parity, marital status and/or spousal consent. For example, on average across six cities, 68.4% of providers restricted the use of injectables based on the number of times a woman had given birth (parity). Consideration of marital status led 71.2% of providers to restrict the use of injectables; 69.7% of providers restricted the use of female sterilization if a woman was not married. Lack of spousal consent led 68.7% of providers to restrict injectables and 66.3% to restrict intrauterine devices (IUD). As highlighted below, condoms were the least restricted method.
Although many service providers had received pre-service training on FP, the baseline survey found that very few had received in-service refresher training in the previous 12 months. Between 0% and 34.8% of the service providers in high-volume, public preferred or private preferred facilities had received refresher training in the year prior to the survey.
The Distance Education Program
The Nigerian Urban Reproductive Health Initiative (NURHI) has trained FP providers in the clinical and non-clinical aspects of FP service provision, including medical eligibility criteria for use of modern contraceptive methods, interpersonal communication between clients and providers, counseling and method-specific clinical skills. The training is usually followed up by supportive supervision. Constant practice and reinforcement are needed to maintain the skills acquired during the training. NURHI staff have found that provider bias – the personal opinion of service providers – is difficult to change, and often remains even following the refresher training.
…it keeps you abreast on what you are expected to do. When you are going off track, it has been a sort of reminder to us and to make us give good services. – Participant in the distance learning course during a focus group discussion
To address provider bias, NURHI launched a distance education program in November 2013. The program uses smart phones loaded with educational content to provide re-enforcement of skills post-training with the aim of increasing providers’ ability and willingness to deliver FP methods to their clients that are appropriate and based on the clients’ desires and medical eligibility. NURHI developed eight videos with four scenarios featuring examples of good (“supportive”) and bad (“unsupportive”) providers. Each scenario features examples of provider biases, including those based on age, marital status and parity. Each scenario begins with a pre-test, and at the end, a post-test is given to gauge what the provider has learned from each scenario.
Results of the Distance Education Program
During Phase 1 of the program (in 2013), 285 phones were distributed to service providers in Abuja (50), Ibadan (84), Ilorin (62) and Kaduna (89). The usage patterns of the phones show minimal disruption to the providers’ work flow given that they accessed the videos either before or after their work day. Users of the program included nurse midwives and nurses that NURHI had trained. There were no doctors among the users as they are rarely involved in FP counseling. The users found the videos and quizzes especially useful.
According to data collected as a part of the 2013 Nigeria mid-term household survey for the Urban Reproductive Health Initiative, important gains were made in quality of care and use of modern FP methods between the baseline and mid-term surveys. With the exception of Abuja, all cities saw increases in the prevalence rates for modern FP methods at mid-term as compared to baseline.
Moreover, in the cities of Ibadan and Ilorin, there was an increase in the percentage of women who stated that a health or FP worker told them about side effects of their chosen methods. Additionally, in Ilorin, there was a 13 percentage point increase in women stating that a health or FP worker told them about methods, other than their method of choice.
“It is our hope that the data from this research can help confirm what the midwives have been self-reporting: that the videos help them recognize the biases they held against their clients and allow them to start changing those behaviors and remove bias as a barrier to adoption of contraceptive services.” – NURHI distance education program design team