Written by: Katie Williams, Fellow, FHI 360 & UNC Gillings School of Global Health
A new module featuring the levonorgestrel intrauterine device (also known as the hormonal IUD) is available via the Training Resource Package for Family Planning (TRP). Developed by a consortium of partner organizations led by USAID, WHO, and UNFPA, this addition expands global availability of high quality family planning clinical professional development resources. Intended for reproductive health providers, trainers, and program managers, this module serves to complete an accessible, adaptable compendium of training resources on the full range of evidence based, modern contraceptive methods featured in the WHO Family Planning Handbook for Providers and the Medical Eligibility Criteria for Contraceptive Use. To launch the new hormonal IUD module, we spoke with three of its most integral contributors.
Interviewees:
Neeta Bhatnagar, Senior Technical Advisor, MOMENTUM Country Global Leadership
Emma Clark, Senior Maternal Health Advisor, USAID, GHSI-III Mechanism
Irina Yacobson, Senior Technical Advisor, FHI 360
Interviewer:
Katie Williams, Fellow, FHI 360 & UNC Gillings School of Global Health
In general, can you tell us about the TRP? What is it and what inspired its creation?
Irina: I think it was sometime around 2008, which seems like a long time ago, when colleagues at FHI 360 and I began to wonder why every project that involves providers’ training starts with curriculum development. From scratch. And national training curricula we see at country level often cannot keep up with evolving global, evidence-based recommendations. We thought to ourselves; wouldn’t it be great if we had some kind of curriculum prototype that can be easily customizable to meet the needs of individual projects and country programs? We approached USAID with this idea, found enthusiastic support, and the rest is history. Afterwards, we invited family planning and training experts from organizations such as Jhpiego, IntraHealth, Pathfinder, and others to conceptualize what this prototype curriculum should look like and how we can ensure that future trainers not only have technically accurate information based on the latest WHO recommendations, but also can rely on effective training methodologies. Eventually, we decided on modular structure and it became “a package.” And, of course, this package had to be a living organism, meaning it must be maintained, keeping up with new developments and global recommendations. Over years, many organizations were responsible for and contributed to keeping TRP alive and in good health, so all I can say is “it takes a village to raise a child” and “parents’ job is never done.” Cliché, I know, but also true!
What led to the recent inclusion of a module on the hormonal IUD in the TRP?
Emma: As a practicing midwife, I know that no form of family planning is perfect, but intrauterine devices and systems have a lot of benefits. The copper IUD has been widely available globally for a long time and works great for many women. But it also has some drawbacks, mostly around heavy bleeding. For people who already have heavy periods or are anemic or just don’t like monthly bleeding profile of the copper IUD, the hormonal IUD seems like a gift and opens up the method category as an option. Of course, the hormonal IUD has its own drawbacks, but that’s the beauty of increased choice- people can find the method that’s right for them and best meets their needs. As hormonal IUDs become increasingly available globally, we were very motivated to make sure they were on the table as an option and the TRP is a great way to do that
What was the development process like for the hormonal IUD module? How did you go from concept to completion?
Neeta: Since its launch in 2012, the TRP website has been updated from time to time to reflect revised international guidelines and updates as well as the addition of new modules. It was last updated almost two years ago by the USAID-funded Human Resources for Health (HRH) 2030 project, with additional revisions to modules and a scope of work to complete the hormonal module. USAID’s MOMENTUM Country Global Leadership took over the management of the website and current activities in March 2020. MOMENTUM Country Global Leadership along with contributions from FHI 360 reviewed the new module, updated, and revised it. It involved literature reviews, adding sessions to include the types of inserters (one- and two-handed) used in the different product, job aids, checklists, new apps and guidelines, etc. The revised module was further reviewed by colleagues from WHO, USAID, and UNFPA. It was finally ready and uploaded to the TRP website. Along this journey, the TRP partners—WHO, USAID, UNFPA, and MOMENTUM Country Global Leadership— met virtually once every two weeks to provide updates, get clarifications and feedback, and discuss next steps on the redesigning of TRP website and module development. This is all truly a result of a teamwork!
Which components of the hormonal IUD module are you most excited about?
Emma: There will be people who are not familiar with the hormonal IUD as an option and I am excited for them to learn about it. I hope it will inspire people to advocate for access to the method in their countries as part of a comprehensive method mix.
Irina: I am a huge believer in job aids for providers. If it were up to me, I would have a job aid for everything. Job aids are not magic, but they certainly can make one’s life easier. So, I am excited that the hormonal IUD module comes with a set of job aids. Some of these job aids are meant to support learning. For example, we have redesigned job aids for hormonal IUD insertion (both for one-handed and two-handed inserter) to make insertion steps as clear as possible. Some job aids support actual service delivery. These include screening checklist for initiation of hormonal IUD, which allows providers to decide if the client is medically eligible for IUD insertion. Another example is the NORMAL tool that helps providers to counsel clients about menstrual changes that accompany some contraceptive methods, including hormonal IUD. Now if only someone could give me a job aid on how to best balance work and life during pandemic, I will be all set!
Neeta: It is really hard for me to single out any section of this module. What is most exciting is that it comprises of different interactive sessions and slide decks - basic, advanced and additional/optional and these can be tailored for use to the local context and learner needs depending on the scope of work and job responsibilities of different cadres of learners. There is adequate time allotted for interactive exercises, role plays, case studies and ‘hand on” skill practice on anatomical models. Also exciting is the inclusion of the new app for WHO's Medical eligibility criteria for contraceptive use, a digital tool to facilitate the task of family planning providers in recommending safe, effective and acceptable contraceptive methods for women with medical conditions or medically relevant characteristics. Moreover, I like the adaptability and flexibility of the sections that gives an autonomy to the user.
How do you balance the development of a standardized resource with the recognition that this will be used in a variety of contexts and by a diversity of users? What makes it accessible and how can users adapt it?
Irina: Good question! From the very beginning, the whole idea was that it should allow for adaptation. Having it in modular format helps programs to shape the content into what they feel suits their needs best at any given moment, and make sure that the adaptation reflects their country’s contraceptive method mix. They can use the package to train on an individual family planning method or use it for a full-blown family planning training course. It takes a bit of time to figure out all the pieces and how they can be linked together. The facilitator guide (general one as well as the guides for individual modules) can help with that. However, any adaptation should be done with understanding that some things are universal, not at all country specific. For example, there is a strong evidence that hormonal IUD (as well as copper IUD) is very safe and effective when used by nulliparous women. This would be true in any country. However, it is possible that country guidelines still say that that the hormonal IUD or copper IUD should not be inserted if a woman had no children yet. So, in such cases, the TRP can also be used to advocate with a Ministry of Health for updating country guidelines instead of making training less evidence based.
How do you envision the hormonal IUD module adding to the knowledge base of those who use it?
Neeta: To keep up with the expanding contraceptive choices and ensure quality and safety of method provision to meet the client’s reproductive intentions, it is essential for the healthcare workers to have updated knowledge and skill set to counsel and safely provide the method of choice to the client. The hormonal IUD module has been updated with current guidance and resources from the WHO’s The Selected Practice Recommendations for Contraceptive Use (3rd Edition 2016) and its Family Planning Global Handbook for Providers (2018). In addition, it has references and resources contributions from technical experts and researchers giving the user of the TRP more details for a better understanding of the topic. The basic slide deck provides an overview of the characteristics of the IUD in a clear, simple, and understandable manner. There is a slide deck on advanced information for more in-depth knowledge and data on certain topics for advanced learning. There are different types and brands of the methods available in the market with variations in types of inserters and insertion technique. The module includes content for both types of inserters - the one handed and two-handed, so the trainer can familiarize learners to both these types and focus on the one that is available in the country. The training schedule allows for learners to practice their skills under guidance of the facilitator
Irina: It depends on the learner’s baseline knowledge and needs, of course. Overall, the module has all necessary components to train a range of providers – it could be someone who just offers counseling for hormonal IUD (in addition to other FP methods), or someone who provides a full range of services, including insertion, removal, and management of the side effects. For providers who are already a part of the workforce, it will be building on knowledge and experiences thy already have. Or it can be used in preservice settings to train future providers, which could be both harder (there is a lot to learn) and easier (no need to re-learn to correct any outdated, but entrenched practices). For trainers, I think working with the module provides a good refresher in a systematic way, while helping them to make training more interactive. In any case, the module contains the most up-to-date information, so hopefully, anyone can learn something new or re-visit/improve the way they were doing things in the past.
Amidst the COVID-19 pandemic, we’ve seen the global rise of telemedicine/health and digital training for providers. Does this resource contribute to that trend?
Emma: Absolutely! While of course we can’t insert methods like the hormonal IUD remotely, telemedicine can actually improve opportunities for screening and patient education because you aren’t as pressed to do education, screening, and insertion in one visit. This resource provides tools to do both things really well, even for a provider new to the hormonal IUD. We’re also having to train some people remotely. Having these materials can provide a core outline for any type of training and can be easily mixed and matched and presented in whatever format and time frame necessary, which makes them a very usable tool for digital training. While nothing can replace hands-on training, detailed guides with many pictures can minimize the time needed for physical hands-on training. Even separate from the challenges with COVID, hybrid training is increasingly becoming the norm, and this is a step in that direction.
We’ve heard that MOMENTUM Country Global Leadership is working on an overall redesign of the TRP. Can you tell us more about that?
Neeta: Over the past year, MOMENTUM Country Global Leadership has facilitated a refreshed vision for the TRP with USAID, WHO and UNFPA. The process was informed by recommendations from a 2018 evaluation done by USAID/HRH 2030 on user trends, experiences, and lessons from the field on TRP usage. The redesign focused around aligning content with the latest approaches for effective and evidence-based learning and guided by principles of human-centered design. It envisions revisiting the TRP structure and making it more appealing to users by improving the onboarding, learning, and training experience, and optimizing it for mobile use in low resource settings. The process included in-depth design research conducted with TRP experts and users across diverse geographies, qualitative and quantitative surveys and consultations from key global and country level stakeholders including regular and potential users, an expert visioning workshop and design explorations for ease of use in navigating and downloading content. From March 2021 onwards, MOMENTUM Country Global Leadership will support the development of the website, including conducting design sprints, before the soft launch of the new TRP in June 2021.
The newly designed website will feature a community forum that will enable trainers to connect, foster knowledge exchange and share individual experiences, successes, challenges and request for support.
For trainers working in low- and middle-income countries who are willing to participate in the beta testing process, I encourage you to contact the TRP group.
Is there anything else you want to share about the TRP or the hormonal IUD module?
Irina: Just the fact that it is out there. Let everyone know it is available. Use it and let us know what you think!
Neeta: The TRP instructional design structure and contents of the module follow the adult learning principles and can be adapted for use for different cadres of learners. It can be adapted for any style of training, for example, face-to-face, blended learning, on-the-job training and for use on virtual platforms combined with ‘in person’ skill demonstration and practice in small groups. It can be adapted for refresher training; training new providers; and pre-service education. Based on the learning needs, it can be used as a stand-alone course on a single method or as part of a comprehensive course in family planning.
The contents of this blog are the responsibility of the authors and do not reflect the views of the U.S. Agency for International Development (USAID) or the United States Government
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