Training
Training on injectables is an opportunity to improve the
overall quality of family planning services. Training programs
have covered basic information about injectables, counseling
skills, and giving injections safely.
The format and length of training depend on the background
of providers. Experienced providers may need refresher training.
They may not mention injectables when reviewing methods with
clients (19, 171, 216, 225, 297) or they may not discuss side
effects (71). In some studies fewer than one-half of clients
starting or switching contraceptives received information about
injectables.
Programs that are introducing injectables have devoted one
or two weeks to training about injectables. In Bangladesh, for
example, a program introducing injectables into community-based
distribution (CBD) programs in two thanas (districts) conducted a
4-week course for CBD agents, one week of which was devoted to
injectables. Surveyed after the course, however, the CBD workers
said that they would have liked even more training—9 to 13 days
(4). To train providers who do not know how to give injections
may require two weeks, including practice giving injections into
fruit and vegetables (144, 211, 254).
Providers also should know how to manage two rare but dangerous side
effects of injectables: anaphylactic shock, a potentially fatal reaction
to an injected drug, and heavy bleeding. There have been four reports
in the medical literature of severe allergic reaction or anaphylactic
shock related to DMPA (43, 189, 315, 353) and a few additional reports
to Upjohn's voluntary reporting database (274). Two women reacted to components
of the solution in which DMPA is dissolved, polyethylene glycol or polysorbate
80, for example. The cause of the allergic reaction in the other women
was not identified. Most women recovered after treatment with epinephrine,
Benadryl® (diphenhydramine hydrochloride), or other drugs. Management
of heavy bleeding may require treatment with oral or injectable estrogen
and blood tests for anemia (333) (see Chapter 4.1 Bleeding
Changes).
Counseling training. To develop providers' counseling
skills, trainers can:
- Emphasize that knowledge of side effects generally
helps women use injectables.
- Set up role-playing, in which trainees improvise a
conversation between a client and a provider. If
possible, trainers can videotape trainees to show them
what they do well and what needs improvement.
- Present case studies of counseling sessions to
stimulate discussion. Trainees may describe the
barriers to good counseling that they face—for
example, lack of privacy—and discuss possible
solutions.
- Discuss critical incidents, situations that trainees
might confront in the clinic and that call for
decisions—for example, a user of injectables returns
with frequent bleeding. Trainees can discuss how they
would respond.
- Arrange for trainees to observe actual counseling
sessions or to counsel clients under supervision.
- Address biases about injectables. Courses in the
Philippines allocate time at the beginning to allow
trainees to voice their concerns. Trainers distribute
research studies and invite an authority on DMPA use in
the Philippines to speak (51).
- Visit trainees three to six months after the course.
Trainers can observe trainees applying their counseling
skills and give them further guidance.
- Set up periodic refresher training. In Bangladesh CBD
workers receive one or two days of refresher training
six months after initial training (211). Also, these
workers can get information once a month when they
return to the clinic for supplies and their salary (4).
Training programs must require trainees to demonstrate the
skills needed to provide injectables—for example, counseling and
giving the injection. Such competency-based training improves on
training programs that simply measure increases in knowledge.
Programs need to decide if trainees should pass a test in order
to provide injectables or train others, or if just attending the
course is enough.