Between 15 April and 31 August 2019, implementing partners ran a three-day or four-day pilot training workshop in each of the three participating countries (Table 1, Part 1). The nature of all three contexts was humanitarian or fragile. The number of participants ranged from 21 to 30 per workshop with a total of 72 people (35 women and 37 men). They were nurses, midwives, physicians, medical coordinators, and programmatic staff affiliated with the partnering organization. In Nigeria and the DRC, members of the Ministry of Health participated in the training. In Nigeria, there were ten community health extension workers and one radiologist—this was contrary to the recommended criteria for participants and part of the lessons learnt (see Discussion).
The core curriculum comprised a day on manual vacuum aspiration and another one addressing medication-based uterine evacuation. On the basis of participants’ needs and available resources, facilitators added a first day dedicated to abortion values clarification and attitude transformation (Nigeria, DRC) and all three workshops included a day of validation of clinical competencies with real clients or through role-plays using humanistic models if no planned clients showed up. In all three countries, facilitators included a discussion on ways to integrate uterine evacuation into health facilities in humanitarian settings, which is part of the monitoring and evaluation chapter of the module.
In all three countries, results for the knowledge pre-test and post-test were available. As mentioned under Methods, data from the competency checklists were incomplete and therefore unreliable for analysis (Table 1, Part 2). In DRC, an evaluation officer conducted three focus group discussions with a total of 5 women and 14 men. In Uganda, due to limited resources, one of the facilitators had to conduct just one focus group discussion with 3 women and 3 men and another facilitator provided written feedback on the use of the facilitator’s guide. In Nigeria, there were two focus group discussions. However, the recording and audio files, which contained the details about the number of participants and their gender, were corrupt and therefore not usable.
Table 1. Summary of key workshop characteristics (Part 1), applied evaluation tools, and results (Part 2) in Uganda, Nigeria, and DR Congo.
Part 1
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Uganda
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Nigeria
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DR Congo
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Partners
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Ipas, Médecins du Monde
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Ipas, CARE
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Save the Children, CARE, Ipas
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Settings
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Bidibidi refugee settlement, Yumbe District, West Nile region
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Maiduguri, Borno State
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Goma, North Kivu
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Dates
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April 2019
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July 2019
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August 2019
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Number of participants
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21 (9 women, 12 men)
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21 (18 women, 3 men)
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30 (8 women, 22 men)
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Professions/ functions
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Physicians, midwives, nurses, clinical officers, medical coordinators
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Physician, midwives, nurses, community health extension workers (n=10), radiologist (n=1)
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Clinical and programmatic staff from CARE and Save the Children
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Duration
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3 days
- 1 day on medication uterine evacuation
- 1 day on MVA uterine evacuation
- 1 day for the validation of clinical competencies
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4 days
- 1 day on values clarification and attitude transformation
- 1 day on medication uterine evacuation
- 1 day on MVA
- 1 day for the validation of clinical competencies
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4 days
- 1 day on values clarification and attitude transformation
- 1 day on MA
- 1 day on MVA
- 1 day for the validation of clinical competencies
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Part 2
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Uganda
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Nigeria
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DR Congo
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Pre-/post-test knowledge scores
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- n with complete data = 18
- pre-test: 84%
- post-test: 89%
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- n with complete data = 20
- pre: 45%
- post: 52%
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- n with complete data = 27
- pre: 56%
- post: 76%
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Pre-/post-training competency checklist
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In-training use but data not collected
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In-training use but incomplete and unreliable data
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In-training use but incomplete and unreliable data
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Qualitative interview
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1 FGD (3 women, 3 men)
1 IDI with co-trainer
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2 FGD (corrupt audio files)
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3 FGD with a total of 19 participants (5 women, 14 men)
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Pre-test and post-test
The average scores of participants rose significantly in all three countries but from different baselines and with different percentage point increase. In the DRC, the score increased from 56% to 76%; in Uganda, from 84% to 89% with the best improvement at +25 percentage point; and in Nigeria, from 45% to 52% with the best improvement at 25 percentage point but a third of participants scored worse after than before. A participant in Uganda reported that the pre-test should be “less bulky, comprehensive, and cumbersome,” an impression echoed by participants from the other settings.
Qualitative results
Confidence, skills building, and relevance
Participants from all three countries reported that the workshop enhanced their competencies, strengthened their confidence by overcoming fear to deliver uterine evacuation information and services, and eventually transformed their attitudes in relation to uterine evacuation.
Before, I even feared to talk about it because I could not even defend my thoughts. I really feared when somebody came to me and talked about abortion: tell me more about it, what is the service? I really did fear because I lacked the evidence, and I didn’t know what I was doing…I used to fear the complications. But I have also learned about how to manage complications and even how they can come about during the process. I know how to help with some of the complications that may come about, how it can also be avoided during the process. – Participant from Uganda.
When asked about what they would do differently as a consequence of the workshop, participants listed improving counseling, respecting all clients, and specific clinical procedures, including the administration of paracervical blocks or medication for pain control, as illustrated hereafter:
What I would do differently? A paracervical block before doing manual vacuum aspiration, pain management using ibuprofen, and know how to administer mife [mifepristone] in combination with miso [misoprostol] or give miso alone. – Participant from the DRC
I will change my attitude. I will do follow up. I will do good counseling. I will have self-confidence, respect for all clients and provide quality care to all clients irrespective of age, religion, and marital status. – Participant from Nigeria
The previous quote came from the Nigeria workshop and suggests that the S-CORT curriculum could influence attitudinal changes related to the quality of care and non-discrimination even without a dedicated day on values clarification and attitude transformation. In addition, the need for non-discrimination was repeatedly underscored as well as freedom from shame, as exemplified hereafter:
This training has helped us not to discriminate anyone who has come for the service. So, you cannot discriminate this one who is young or this one who is old so you cannot do the procedure. It has helped us to do abortions to any client who really wants the service…I feared talking about abortion but now I’m okay because sometimes I see people dying, but I think helping these people about abortion is better than leaving them dying. And right now, I have come to really believe that with the knowledge I got, with the medical method and the evacuation, I can really help a lot of people in crisis and also, I will not feel so ashamed to talk with them, to counsel them so that I will not lose them. – Participant from Uganda
Participants reported the need to have a more concrete discussion—and examples—on how to improve the integration of their uterine evacuation skills into their healthcare services, as most providers found the training workshops relevant to their job:
This knowledge is very relevant to my profession being a comprehensive nurse. I have to know everything. Basic things in the medical profession so that I am able to handle any case. I cannot say this is a maternity case or this is a gyne[cological] case that has to be handled by midwives or doctors or something of that kind. So, I feel that this knowledge is very relevant to me so that it will help me to manage any case which presents to me. – Participant from Uganda
Counseling, human rights, and the law
Participants seemed adamant about the effect of the training on the way they would do counseling, reporting that their counseling would be underpinned by human rights principles, such as client autonomy and choice. In addition, the workshop appeared to have helped clarify the country's legal framework for service providers, paving the way for fearless counseling and service provision.
I will do this service better since the grey areas I had were lifted with this training, since safe medical abortion is already allowed by the law of the country since it is a need felt in the population despite the ignorance of some. – Participant from the DRC
I have not been going through the counseling. But now, I realized much about counseling. And I have also realized that uterine evacuation goes hand in hand with counseling and then family planning. This one I did not know much about it… It is very important that you make her aware of the different types of family planning and the way we will do this uterine evacuation, being medical, being manual vacuum aspiration. So, that has really helped so much [to understand] that the woman, herself, will be able to decide what she wants, which choice she wants…This training really has helped change our attitudes because some of us used to think it should only be done to people who have been raped: they just sympathize with them, and induced abortion should not be done to others… – Participant from Uganda
Training methodology
Participants highly appreciated the balance between theory and practice through role-plays and skill rehearsal. The humanistic anatomical models were critical for skills demonstration by facilitators and for hands-on practice by participants.
The practice on the anatomic models and the exercises helped me assimilate the contents. However, we did not practice on [real] clinical cases, and the course was taught in a hurry. – Participant from the DRC
Many participants agreed with the perceived short duration of the workshop and the lack of clinical practice reported in the previous quote. Participants suggested adding one to two more days to their workshop, including the opportunity to practice with real patients in clinical settings. In all three countries, there were no patients available for the day planned for practice at the clinic. In this regard, trainees suggested the following actions for the organization of future workshops:
Prior to the training, we can liaise with facilities around to pool of patients possible for clinical practicum. Each case will offer an opportunity for further discussions. A day or two will need to be added for this purpose. A visit to one or two camps will help facilitators describe in clearer terms how services should be organized. – Participant from Nigeria
Participants generally appreciated the quality of the training materials but also reported a few gaps. As reflected earlier on the data incompleteness of the competency checklists, participants reported the need for clear instructions on how to use these checklists to practice skills and validate competencies. In addition, due to local delays in organizing the workshop, several participants in the DRC regretted not receiving hand-out documents.
No distribution of teaching aid before, during, or after the training. We will not know how to review the contents after the workshop. – Participant from the DRC
The materials are easy for the participants to understand. However, there is a need to improve on the instructions for the practical simulation and how co-participants can score themselves. – Participant from Nigeria
Participants shared other recommendations on how to improve their training experience. Figure 2 summarizes the key recommendations under four categories: curriculum revision, pre-workshop preparation, during the workshop, and after the workshop.
Figure 2. Summary of recommendations to improve the capacity development continuum