Data for this analysis come from a larger implementation science study conducted between 2015 and 2018 that looked at the feasibility and acceptability of PPMVs’ provision of progestin-only injectable contraceptives . This analysis uses data collected from PPMVs in four Nigerian states - Bauchi, Cross River, Ebonyi and Kaduna – at three time points. The regulatory body for PPMVs in Nigeria, the Pharmacy Council of Nigeria (PCN), recruited PPMVs for the study based on the following criteria: (a) licensure with PCN; (b) interest and willingness to participate; (c) ability to read and write in English; and (d) commitment to attend all the training sessions.
Between May and June of 2017, 229 PPMVs were trained in FP counseling and the provision of progestin-only injectable contraceptives (counseling, sale, referral and administration). The training lasted five days and was facilitated by two FP trainers certified in Nigeria. The curriculum was based on previously used materials developed by PATH  and FHI 360  and covered the following topics: (a) FP counseling; (b) injectable client screening and counseling; (c) intramuscular (DMPA-IM) and sub-cutaneous (DMPA-SC) administration of injectable contraceptives (including the re-injection grace period); (d) commodity storage; (e) sharps disposal; (f) infection prevention practices; and (g) pharmacovigilance. Each PPMV received a copy of the curriculum at the beginning of the training.
During the training, PPMVs were given three job aids: (a) the Contraceptive Medical Eligibility Criteria (MEC) wheel; (b) Balanced Counseling Strategy Plus (BCS+) cards; and (c) a DMPA screening check list. The MEC wheel provides information on which contraceptive methods are safe for women based on their health characteristics . BCS+ cards assist health care workers in providing clients with targeted and quality FP counseling . The DMPA screening checklist assists providers to screen injectable contraceptive clients based on their medical eligibility .
At the end of the training, PPMVs were required to demonstrate competency in DMPA-IM and DMPA-SC administration on dummy models before continuing in the study. The trainers used a standard observation checklist to determine competency. Four PPMVs were excluded from the study because they were unable to demonstrate competency. After the training, a monitoring team comprised of the research team, trainers, and federal, state, and local Ministry of Health representatives visited PPMVs to identify knowledge gaps and challenges, and to offer feedback to PPMVs. PPMV-client interactions were not observed during these visits and PPMVs were informed when the monitoring visit would take place.
Eight data collectors administered three interviews to PPMVs- a pre-test interview immediately before the training, a posttest interview immediately after the training, and a follow-up interview 9 months after the training. The data collectors were trained in research ethics, the study’s design and the questionnaires approximately two weeks before PPMVs were trained. Informed consent was received from PPMVs before the pre-test interview, and before the start of the 9-month interview. All three tools included identical knowledge questions on injectable contraceptives (e.g. frequency and administration location, counseling on side effects, and eligibility criteria). The pre-test interview also included questions on respondent characteristics and their experience providing injectable contraceptives. The 9-month interview included questions on PPMVs’ provision of injectable contraceptives and FP services, and their experience with the intervention (e.g. training, job aids and monitoring visits).
Three outcome variables were used to assess PPMV’s knowledge of progestin-only injectable contraceptives: (1) DMPA-IM knowledge; (2) DMPA-SC knowledge; and (3) progestin-only injectable side effect knowledge. The DMPA-IM variable was created by combining three knowledge questions: (a) the type of device used to administer DMPA-IM; (b) where DMPA-IM can be administered on the body; and (c) the reinjection frequency. A dichotomized variable was created and coded as 1 if the PPMV answered all aspects of each question correctly, and 0 if the PPMV answered any part of the three questions incorrectly. The DMPA-SC knowledge variable was based on the same three questions listed above but were specific to DMPA-SC. A similar dichotomized variable was created and coded as 1 if the PPMV answered all three questions correctly and 0 if they answered any question incorrectly.
The side effect variable was based on PPMVs unpromoted response to the question “what are the common side effects of progestin-only injectable contraceptives.” The seven possible responses include: change in menstruation, headaches, dizziness, weight gain, mild skin irritation, decrease in sex drive, and delayed return to fertility. A dichotomized variable was created and coded as 1 if the PPMV named at least 4 of the 7 common side effects and 0 if the PPMV named less than 4 of these side effects. Four was used as the cut-off based on the distribution of side effects PPMVs correctly named at the posttest interview.
The main predictor was PPMVs’ self-reported use of job aids. At the 9-month interview, PPMVs were asked whether they used the jobs aids distributed during the training when providing FP services to their clients. Those who reported using job aids were then asked which job aids they used. The variable was dichotomized and those who reported using none or one of the job aids were coded as 0 and those who reported using two or three job aids were coded as 1. The other main predictor variable was administration of an injectable in the 30 days preceding the survey to determine whether providing injectable contraceptives recently affected PPMVs’ knowledge. The variable for administering an injectable contraceptive in the past 30 days varied by model. Administration of DMPA-IM in the past 30 days to a client was used for the model focused on DMPA-IM and administration of DMPA-SC in the past 30 days to a client was used for the model focused on DMPA-SC. For the model with side effect knowledge as the outcome, administration of any type of progestin-only injectable was used. These variables were coded as 1 if the PPMV reported administering the injectable to at least one client in the past 30 days and 0 if they did not administer an injectable in that timeframe.
Additional covariates that were considered in the analysis include: (a) sex; (b) age; (c) education; (d) marital status; and (e) state where PPMV shop is located. Sex, age, education and marital status were included as co-variates to account for variation due to participant characteristics. State was included to account for any regional differences. Other variables considered due to theoretical importance were previous health facility experience and receiving a monitoring visit by the study team. Previous health facility experience was not included in the model because it was not a statistically significant predictor of any of the outcome variables at the post-test or 9-month interview in the bivariate analyses. Receiving a monitoring visit was also excluded from the models because almost all PPMVs received the 6-month monitoring visit.
Age was dichotomized at the median age of 35 and the variable was coded 1 if the PPMV was 35 or older and 0 if 34 or younger. Education was dichotomized so that those who had at least two years of post-secondary education were coded as 1 and those who had completed a primary or secondary education were coded as 0 (all the participants had a least a primary education). Marital status was dichotomized, and the variable was coded as 1 for those who were currently married and 0 for those who were single, divorced or widowed. State was a categorical variable with a category for each of the four participating states.
The sample was restricted to PPMVs who completed all three interviews. Of the 225 PPMVs enrolled in the study, 31 PPMVs were unavailable at the time of the 9-month interview, bringing the analytical sample to 194. Descriptive statistics were calculated for PPMV characteristics. Pearson chi-square tests were used to assess trends in knowledge over time. Significance was determined using a probability value of 0.05 or less. Unadjusted odds ratios were first calculated to assess whether certain PPMV characteristics predicted the likelihood of DMPA-IM, DMPA-SC, and side effect knowledge. To determine factors associated with injectable contraceptive knowledge at the 9-month interview, one multivariate logistic regression model was conducted for each of the three outcome variables.