Where there are few screens: Digital training for self-care in the pandemic and beyond

by Beth Balderston, Communications Officer and Dr. Jane Cover, Research and Evaluation Manager, PATH

Contraceptive self-injection holds great potential for expanding women’s family planning options by putting the power of prevention directly in women’s hands, which reduces access-related barriers and enhances autonomy. Especially during a pandemic like COVID-19, injecting at home can also help reduce women’s exposure to illness by reducing their trips to a crowded facility for their injection. Self-injection can also reduce pressure on overloaded health systems, given fewer client visits for injections.

Training both health providers and clients is key to successful self-injection—once community health workers, midwives, and other health workers are trained, they can help a woman learn to inject on her own. Unfortunately, training itself has become increasingly challenging during the COVID-19 pandemic. Physical distancing guidelines have placed limits on how in-person training can be conducted, and in many places, this has slowed or paused training efforts.

At the same time, pandemic restrictions have created opportunities. More programs worldwide have renewed interest in digital training and support approaches to keep family planning efforts moving forward—even among health workers in remote settings and limited technological capacity. By leveraging digital platforms, programs can reduce the costs, time, and inconvenience associated with traditional classroom training, eliminating the need to pull critical health workers away from urgent demands. While digital training does not completely replace invaluable in-person follow-up to ensure quality of care, it can open the door to more flexible solutions, as family planning programs can combine approaches, including interim approaches, depending on what meets their needs.

To learn more about how innovative training approaches can keep programs moving forward, PATH’s DMPA-SC Access Collaborative has developed and evaluated digital training resources for both health workers and clients who are learning about self-injection alongside other contraceptive options.

eLearning for health workers: An important tool in the toolbox

Self-directed eLearning courses have been around for years in various public health fields but have not been used extensively in family planning programs, including for the self-injectable subcutaneous DMPA* (DMPA-SC). PATH’s DMPA-SC online course for health workers includes ten lessons with an emphasis on informed choice counseling and training clients to self-inject. The course can be taken on a computer or mobile device with internet access.

After developing the course, our team conducted a study in Uganda with approximately 600 public, community-based, and private-sector health workers to evaluate its feasibility, accessibility, and effectiveness. Most of these participants had not been trained in DMPA-SC. Health workers who finished the course were then invited to an in-person practicum where they practiced injecting and received feedback.

Photo: PATH/Will Boase

Health workers who completed the course performed well on a DMPA-SC knowledge test, with nearly 90% scoring above 80%. And while eLearning is not usually as effective for skills-based training, participants, including community health workers, demonstrated relatively high injection competence: about 7 in 10 demonstrated competence without any posttraining practice or guidance.

The practicum then helped health workers build on their injection competence and confidence. While before the practicum, less than half reported that they would feel very comfortable injecting a client, afterwards, more than 90% said they would.

Participants did not perform particularly well on a basic family planning knowledge test, with just 4 in 10 scoring above 80%. This 12-question test covered topics not included in the DMPA-SC course in order to assess health workers’ general understanding of family planning. The results highlight the importance of strengthening training and supportive supervision for health workers on all contraceptive methods.

Rolling out the course also had its challenges: health workers cited internet connectivity, finding time to take the course, and mobile phone issues as their most common challenges to course completion. Notably, only about half of those who enrolled completed it. Those who did not finish said that better access to smart phones, more time, and more money for data could help them.

This evaluation showed us that a strong eLearning program needs several key elements, including technical support for health workers, mobile data plans to reduce costs, monitoring of participants’ progress and reminder messages, and recognition for completion.

And while online courses are often taken independently, follow-up support and guidance are critical components. The practicums in Uganda made a big difference in helping health workers apply their course knowledge to hands-on practice. However, these were held right before pandemic physical distancing guidelines were established. Since then, we have explored a few options for remote support and supervision, such as using live chat, SMS, video, as well as peer support. PATH is also conducting a second evaluation of eLearning in Senegal in collaboration with the Ministry of Health and Social Action. Results are expected in late 2020.

Video self-injection self-training for clients: A promising approach

Research has demonstrated that women can self-administer DMPA-SC safely and effectively, and that they like doing so. However, in-person self-injection training approaches to date take about 30 minutes on average (after a general informed choice contraceptive counseling session), and many health workers report that there are days or times when they cannot offer self-injection training because they are too busy.

Photo: PATH/Will Boase

In order to explore alternative training solutions, PATH conducted research on using a self-injection training video as a tool for client self-training. Through this study, we aimed to understand whether women could self-train (unassisted) using either a printed job aid or video, then demonstrate the injection technique on a model.

The study found that the video was more effective as a self-training tool compared to the job aid—overall about 7 in 10 participants who viewed the video showed practice injection competency  (highest among private-sector clients), compared to less than 4 in 10  among those who used the job aid.

Almost all women who were trained with the video said they would like to watch it again when they self-inject. As one client remarked, “If I have the video and I switch it on, I will be able to see how it was done at the different steps.…It reminds you when you watch the video again so that you can self-inject at home.”

At the same time, even those clients who liked the video and injected correctly said they value additional in-person training support. Almost all clients mentioned a preference for provider involvement. One client remarked, “I think it would be nice if, as I train, I can ask questions about what I’m seeing and the provider answers them. It would have made me master the steps in the video better.”

These research results hold promise for client self-care, including self-training. During the COVID-19 pandemic, for example, clients with phone and internet access could watch a self-injection training video at home. This could then shorten their visits to pick up injection supplies and ask questions—reducing infection risk for both clients and health workers. If and when such approaches are rolled out, it is critical to monitor use and uptake for equity implications to make sure that not only a privileged few are able to access these tools and approaches.

Now more than ever, remote communication and training options are in demand. While training and supporting health workers and clients are among the biggest cost drivers when introducing any innovation, adapting digital approaches so we learn from evidence and experience can help make self-care a reality during the pandemic and beyond.

* DMPA: Depot medroxyprogesterone acetate.

Banner Image: PATH/Will Boase