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Issue-3 : Training of Healthcare Providers

Background

Preintroduction strategy for any new product lays a great deal of emphasis on sensitization of users and providers. Past experience in the field of Family Planning methods especially in relation to intra-uterine devices and oral pills calls for a great deal of preparation, before the actual availability of product for wider usage.

A survey of healthcare providers has revealed poor awareness of even postgraduates in Obstetrics and Gynaecology about the methods of Emergency Contraception, their correct timing and doses, mechanism of action etc. Thus, if EC is going to be introduced in India, for successful prescribing of emergency contraceptives, a great degree of sensitization, preparation and training of both Government and private healthcare-providers is needed.

Questions to be Answered

The Group needed to answer the following questions:

A. Who will be trained?

B. Who will provide the training?

C. Where will the training be conducted?

D. What will be the duration of training?

The training curriculum for different levels of healthcare workers including indications, timing, dosage, history, examination, counselling about side-effects, efficacy and follow-up needs to be decided.

The model training modules prepared by WHO and Population Council were made available as background material.

Views of the group

The Group divided the issue of training in three levels depending on the level of the healthcare functionary, and identified the trainees, the trainers, the venue, the, duration of training and training curriculum at each level.

Level I - Training at Primary Healthcare Facilities

This will include training of Primary Health Centre (PHC) doctor, Lady Health Visitor (LHV) and Auxillary Nurse Midwife (ANM), as these form the backbone of National Family Planning Programme. Traditional birth attendants (TBA) and Anganwari workers may also be included. Each one of these health functionaries will need training in Emergency Contraception before making it available for wider use.

The training to PHC doctors can be provided by District level Health officials, while others can be trained by the PHC doctor at PHC itself.

Training can be spanned over 1-2 days in split sessions and at this level, periodic refresher training will be required.

There is need to provide a training manual written in simple local language with answers to probable clinical problems and situations that may arise in the field. This will act as a source of ready reference for trained providers.

Level II - Training of General Practitioners

This group should include all private practitioners, district medical officers, CGHS/ESI dispensary doctors, medical officers and all primary care and family physicians.

The training can be provided by Obstetrics and Gynaecology specialists as well as Indian Medical Association (IMA) members who are providing contraceptive services.

Professional bodies can play a lead role in this training by building it into their monthly, quarterly and/or annual meetings as well as by conducting specific workshops or focussed CMEs. Training session can also be conducted during monthly block level meetings at the District level.

A one-day session is adequate; a follow-up session can be done at the next monthly meeting to clarify doubts and to answer questions.

Written material needs to be provided in advance to officials attending these training sessions.

Information on EC should also form an integral component of Undergraduate Medical, Nursing and Pharmacy courses.

Level III - Training to Specialists

This group will primarily include obstetricians and gynaecologists, IMA members involved in providing contraception, postgraduates, etc.

The training is to be provided by a core group of experts, from medical colleges, FOGSI, ISoPARB etc.

This training can be conducted at zonal or state level and can be built into workshops being conducted for RCH training by the Ministry of Health & Family Welfare.

Usually, a half-day session will be adequate for this level of healthcare functionaries.

Providing written material is important for successful training.

A curriculum for training of doctors and health workers in EC was also defined by the Group considering this issue. They decided that the curriculum should comprise the following components:

(i) introduction it should define what is Emergency Contraception, emphasize usefulness of such a method and highlight major plus points about this method as well as mention about the negative aspects.

(ii) Indications for EC use need to be defined properly.

(iii) Methods of EC including their mechanism of action, dosage, side-effects, efficacy, etc.

(iv) Pre-therapy work-up of clients including history-taking, examination and counselling with special emphasis on date and time of unprotected intercourse, date of last menstrual period and use of other contraception. Pelvic examination is not necessary. All the potential users should be counselled about failure rates and side- effects.

(v) Inclusion and exclusion criteria need to be clearly explained.

(vi) Expected side-effects, remedial measures, follow-up and management of Emergency Contraception failures.

Discussion

During discussions, the Expert Forum emphasized on the need of involving all organizations in the training programme, including even the Gram Panchayats. It was decided to train a group of doctors initially as trainers, who can then train others in their state and family planning units. Incorporating EC training into existing RCH training was considered to be a better option.

Need was expressed for periodic refresher courses at District and PHC level. A multipoint, multilevel training was considered more appropriate. Continuous CME programmes were considered to be more useful than snapshot training. The Expert Forum also emphasized the need of having supportive supervision, where a supervisor is present during the actual prescription sessions and gives suggestions or solves problems.

A more problem-oriented training curriculum was considered more appropriate for grassroot level functionaries. It was decided to adapt the already available training modules to Indian flavour. Training modules should include solutions to practical problems on EC prescription which may be encountered in the field.

Initially training of master trainers needs to be carriedout, selecting them from each state/zone, followed by zonal workshops and subsequently dissemity the knowledge till the grass root level.

Training should not confuse grass-root workers with multiple products and should be focussed on the dedicated product.

Unresolved issue

Targeted training is possible only when a dedicated EC pill is made available. Starting training without ensuring availability of drug is of no use.

 

Recommendations

2.3.1 Multiple-level training is required involving all healthcare providers.

2.3.2 It is important to involve all professional organizations and train the trainers first, who would then train others.

2.3.3 International standard training modules can be adapted to suit the Indian context.

2.3.4 The training curriculum needs to be more problem-oriented than theoretical.

2.3.5 A standard training kit with a slide-show to be prepared for standardized training throughout India.

2.3.6 Lectures on EC to be included in Medical, Nursing and Pharmacy college curriculum.

2.3.7 Periodic refresher training needs to be built into the existing RCH training.

 

 

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