Integration of GTI Management with Family Planning Service Delivery: Lessons Learned in Zimbabwe 

Kay Schmeding, PhD 
International GTI Consultant 
Rockville, Maryland 

Lynne Gaffikin, DrPH 
Director, Research and Evaluation 
JHPIEGO Corporation 
Baltimore, Maryland

Printer-friendly version (35k, Adobe® Acrobat®)

Introduction

In 1993, the Zimbabwe National Family Planning Council (ZNFPC), with support from JHPIEGO, undertook a training project which had the following objectives:

• Decentralize family planning training in Zimbabwe,
• Strengthen IUD/GTI service delivery skills of preservice midwifery trainees,
• Develop a core group of ZNFPC trainers able to train service providers and clinical trainers in IUD/GTI skills, and
• Develop a core group of FP service providers with the ability to deliver IUD/GTI services competently in a clinic setting.

To achieve these objectives, the ZNFPC produced resource and training materials specific to Zimbabwe and undertook a series of training activities designed to produce a cadre of GTI/IUD clinical skills trainers. In addition to three formal courses, several providers received training “on the job.” None of the ZNFPC trainers or any of the providers had any previous “hands-on” experience with the microscope. Three of the providers had never inserted any type of IUD; others were unfamiliar with the TCu 380A.

Post-Training Assessment Objectives

A 6-month post-training assessment was carried out to assess the skills and on-the-job performance of trainees who participated in the IUD/GTI training courses and to determine the impact of this training on service delivery. The post-training assessment was designed to answer questions in several categories as shown in Table 1.

Table 1. Post-Training Assessment Questions

Category	Question
Training Effect	Has there been an increase in the number of GTIs diagnosed/treated at the clinic site since training?  Has there been an increase in the number of IUDs provided since training?
Trainee Competency	Are the providers who attended the IUD/GTI clinical skills courses competent to provide GTI services (diagnosing, treating, managing)?  Are the providers who received IUD/GTI training on the job competent to provide GTI services?  Has the IUD/GTI training resulted in positive service provider attitudes toward the IUD?  Do service providers who did receive IUD/GTI training know about the GTI services offered at their clinics?
Client Perceptions/ Knowledge	Are FP clients aware that GTI services are offered by the clinic they regularly attend?  Are FP clients satisfied with the IUD and FP related services offered by the clinic they regularly attend?
Support System	Are service providers receiving the support they need to deliver GTI services? (system for supervision; management support; adequate client load)  Is there a functional system for resupply of contraceptives, reagents and antibiotics?
Future Training	Can future IUD/GTI training be conducted at facilities where trained providers presently are located?  What is the long-term potential for on-the-job training?

Assessment Methodology

This assessment was designed to examine the effect of the IUD/GTI training in the service setting by using a variety of qualitative and quantitative methods. It was conducted by ZNFPC with assistance from JHPIEGO over a 2-week period, approximately 7 months after the second IUD/GTI clinical skills training course. A total of 16 service providers from 15 different sites were identified for inclusion in this assessment. Two teams of five members each were formed for the data collection phase and included individuals with technical expertise in IUD/GTI management. Each team consisted of two ZNFPC staff members (one of whom had participated in the formal IUD/GTI training course), two members from the Ministry of Health and Child Welfare (MOHCW) and/or City Health and an external consultant from JHPIEGO.

All trained service providers from sites represented in the training courses were included in the assessment. The sites were defined by geographic locations and team membership was defined by geographic work location. Teams were sent to the opposite geographic location from their employment location to minimize the influence on data collection of the perception or appearance of team members as supervisors.

Data collection consisted of interviews (with clinic manager, service provider and clients), self-administered questionnaires, observation checklists, and record and stock reviews along with informal interviewing opportunities arising during the assessment day. All instruments included the option for recording the data collector’s comments about supplemental observations and discussions.

Instruments included:

• Clinic Profile: interview with the clinic manager
• Records Review/Commodities Inventory: review of records and from an inventory of equipment/ commodities at the facility
• Provider Profile: interview with the service provider
• Provider’s Knowledge Questionnaire: self-administered
• Provider’s Attitudes Questionnaire: self-administered
• Counseling, Clinical, Diagnostic, and Treatment Skills Checklist: observation of the service provider
• Client Interview: interview with the client
• Overall GTI Assessment/Training Capabilities: overall assessment and improvements needed for an efficient provision of GTI services

Performance standards for the assessment were as follows:

• The IUD/GTI knowledge and clinical skills of all FP providers in a selected site were assessed, regardless of whether they were trained in a formal course or on the job, or not trained.
• If there were no IUD clients, IUD clinical skills were assessed using the ZOE^® model. 
• At seven sites, GTI skills were assessed only if IUD acceptors (both new acceptors and clients who already had IUDs) were seen. At five sites, GTI skills were assessed with clients who presented with a history of vaginal discharge or lower abdominal pain.
• All clients observed were interviewed with a minimum of two observation/interviews, as were a random sample of three other clients attending the clinic.

Results

Attitudes of Providers

When asked to choose one statement from a list of five statements reflecting various opinions and beliefs about IUD use in Zimbabwe, almost all providers (98 percent) chose the following statement reflecting a positive attitude to IUDs, whether or not they received formal training.

“It is a good method of contraception and health professionals should get more training in order to provide it properly.”

Many providers (84 percent) stated that the training received changed their attitude toward IUD use. But those who responded negatively, when asked why it didn’t change, stated that they had held a positive attitude toward IUD use before training.

Providers were asked to define their perceived risk (high risk or not) for contracting HIV and “other organisms” for five different contraceptive methods where there is exposure to blood and/or body fluids (injectables, IUDs, tubal ligation, Norplant implants, vasectomy). More than half of the service providers ® responding felt they were at high risk of contracting HIV from providing any of the five methods. Despite the emphasis during training on improved infection prevention practices and the relationship to provider protection from infection, there was no significant difference for any method between providers who had been through training and other providers. This attitude reflected their belief that HIV/AIDS and GTIs have high prevalence rates in their community.

Attitudes of Clients

About one quarter of the women interviewed were coming to the clinic for the first time. Many had been coming to the clinic for services for more than a year. Almost all were coming for family planning services. Many clients were aware that GTI services were available at the clinic they regularly attended. Of those who had received GTI services at their regular clinic, most were satisfied. Specifically, women cited as sources of satisfaction the reasonable waiting time and the opportunity to receive all care in one place and from the same provider.

When clients were asked about their preferred contraceptive methods, many said they would not personally recommend the IUD to family members or friends but believed the IUD was good for “women in general” to use. Clients cited positive “local community” experiences with the IUD although personal and familial experience may have been negative.

Service Delivery Practices

IUD insertion technique was performed well by all service providers, irrespective of training status. Risk assessment for GTIs and counseling skills often were poor, however, due to low client load and providers’ lack of practice. During informal discussions, many providers revealed their belief that GTI screening was necessary only for new IUD clients. Syndromic GTI diagnostic skills were found to vary by clinic site. Microscope skills also varied widely by clinic site observed, but all providers, irrespective of training status, were found to need reinforcement. Confidence in microscope skills often was low due to lack of post-training followup or supervision.

Organizational Support Systems

All clinic sites were found to be adequate for FP and GTI service delivery. Contraceptive commodities generally were well stocked. Antibiotic supplies, although better in MOH/City Health clinics than in ZNFPC clinics, often were low and inadequate. Reagent resupply mechanisms were found to need clarification.

Managers were generally supportive of integrating GTI and FP services. They were pleased to have a wider range of services available for clients although some cited problems with resupply as barriers to increasing the numbers of services. In general, the perceptions of the managers about what the training was supposed to achieve were different from those who actually took the course. For example, in informal discussions, it was revealed that many managers did not seem to be aware of the need for a minimum client load for providers to retain their skills after training. They assumed that if the provider had participated in the formal training program, this was sufficient for providing service delivery. Furthermore, managers had a misunderstanding about their roles as supervisors. They had never been trained to be supervisors and they lacked confidence in their ability to oversee providers delivering GTI services. Consequently regular post-training followup and supervision often were absent.

Client Records and Contraceptive Service Statistics

Record keeping was quite variable. There did not seem to be uniform standards for collection of contraceptive service statistics and/or GTI statistics on a daily or monthly basis in ZNFPC clinics. Most clients seen were not registered at the clinic nor given the client cards which were needed for assessing FP continuation, making referrals and maintaining continuity of care. Furthermore, supervisory review for appropriate case management also was impossible without client cards.

Impact of IUD/GTI Training

There was no evidence of increased IUD use or increased numbers of GTIs diagnosed and treated in most of the 15 clinics assessed. The lack of evidence was due, in part, to the lack of reliable contraceptive service statistics and/or GTI statistics. Nevertheless, the integration of GTI services into the 15 clinics assessed has added a new type of service to the health delivery setting. The level of integration of GTI services into FP service delivery was too varied to generalize across all sites:

• Five sites have begun to integrate GTI services “fully” into the clinic setting. All FP clients are screened for GTI risk factors and for GTI symptoms. Those with risk factors or symptoms are examined and a diagnosis is made based on risk factors, symptoms, signs and microscopic findings; those with evidence of a GTI are treated and counseled.
• Seven sites have begun to integrate GTI services “partially” into the FP clinic setting. Only those clients requesting an IUD are screened for GTI risk factors and for GTI symptoms. Those with risk factors or symptoms are examined and a diagnosis is made based on risk factors, symptoms and signs (little microscopy); those with evidence of a GTI are treated and counseled.
• Three sites showed no evidence of integration of GTI services. The integration of GTI skills acquired during training has been very difficult because of inappropriate trainee selection. Seventeen of the twenty-nine providers selected for training were not providing FP services on a regular basis. Although they had a strong desire to integrate their GTI skills into the family planning services they provided, trained providers lost confidence in their FP skills due to the lack of post-training reinforcement. The trained providers who best integrated their GTI skills and maintained their confidence were those who sought a colleague to reinforce their skills.

Lessons Learned in Zimbabwe

Lessons Learned from Trainee Selection 

To ensure the development of a core group of FP service providers competent to deliver GTI services in their clinic setting and provide IUD/GTI on-the-job training to other providers, careful selection of the service providers to be trained is important. It is essential to select providers for training who provide FP services (including IUD insertion) on a daily basis and who have enough time in their daily schedule to add GTI services. Furthermore, they must who work in clinics where the need for GTI services exists, the management is supportive and facilities are adequate. Even if all these prerequisites are carefully considered, service providers who receive no post-training reinforcement will have difficulty maintaining confidence in their ability to deliver GTI services.

Lessons Learned from the Formal Training Experience

• GTI screening, diagnosis and management are a new reproductive health service that redefines the role of FP providers in the clinic setting. Many GTI skills are new to the provider. Formal and on-the-job GTI training requires more emphasis on:
• GTI screening and risk assessment techniques: the importance of GTI questioning skills to assess risk and to elicit essential information about a client’s symptoms cannot be overemphasized.
• GTI prevention messages and ways to deliver them: all clients with identified risk factors, not just those who request an IUD, need prevention messages.
• GTI record keeping: adequate records are essential for client management, to ensure adequate supplies of antibiotics and to aid in post-training reinforcement.
• Client management, especially counseling and partner treatment: like GTI screening and risk assessment, GTI counseling requires providers to discuss personal sexual practices with their clients—a difficult role for them.
• Infection prevention in the clinic setting: providers need to understand exactly what they can do to protect themselves and their clients in the clinic setting.

Lessons Learned about the Need for Developing Country-Specific Objectives

Country-specific MOH prevalence data were used to develop algorithms for five GTIs, and drug lists recommended by the MOH were used to develop treatment protocols. Furthermore, training in questioning and counseling skills was based on Zimbabwe cultural patterns and mores regarding sexual practices. The time spent developing country specific-materials contributed to the success of both formal and on-the-job GTI training.

Lessons Learned from the Application of Skills Post-Training

It is important to emphasize the need for GTI risk assessment and screening for all FP clients rather than for IUD acceptors only. If providers limit delivery of GTI services to first time IUD acceptors, they may lose competency unless the number of IUD acceptors is high. Furthermore, they may miss opportunities for providing many clients with GTI services, especially risk assessment and prevention messages. It is also important to emphasize the need for post-training reinforcement of GTI knowledge, skills and attitudes. When there is little followup and providers are left on their own, some will discontinue GTI service provision because they have lost their confidence or because they find themselves in an environment which is not conducive to the delivery of GTI services. Some may provide only partial GTI services (e.g., screening and prevention messages) or may have to seek reinforcement from other trainees or from sources outside their clinic setting.

Conclusions

Successful Integration

A trained service provider’s ability to integrate IUD/GTI skills into the clinic setting depends upon the:

• number of clients for GTI screening,
• ratio of trained IUD/GTI service providers to daily client load,
• level of management and organizational support, and
• opportunity for skills reinforcement.

The trained provider is most confident and competent when there is adequate time for service delivery, an appropriate client load, institutional support and resources for skills reinforcement.

Implementation of a New Reproductive Health Service

• GTI screening, diagnosis and management are a new reproductive health service, not just a strengthening of existing skills. It redefines the FP providers’ role in the clinic setting.
• There was a lack of clarity about the providers’ new skills and thus the new role to be assumed by the trainees. Their lack of confidence about their competence in their newly acquired skills made it difficult for them to apply their skills. A lack of clarity about the supervisors’ role also hindered the trainees in using their new skills.
• Training must be viewed as a process. Before training for the new reproductive health service even begins, managers need to determine what is needed in the organization to support those who will be trained.
• The addition of microscopy as an aid to diagnosing suspected GTIs requires the provider to learn a new set of skills and to apply these skills in the clinic setting. The provider must have the opportunity to practice the new skills or they will be lost.
• The microscope gives visibility to the provider’s GTI skills and essentially revises her/his role in the clinic setting.

GTI Management

• The FP service provider’s understanding of the importance of GTI screening and risk assessment for each client often is not translated into practice in the clinic setting. Specifically, the provider must understand that clients with risk factors, symptoms and signs positive for a GTI should be screened for GTIs.
• Providers tie GTI screening too closely to IUD insertion (as they were trained to do) and miss many opportunities for screening other clients.
• Providers do not focus on the importance of the GTI screening history as a means to assess risk and to elicit essential information about a client’s symptoms.

Overall Conclusions

Genital tract infection services can be integrated into FP service delivery settings. Family planning service providers can acquire the knowledge, skill and attitudes necessary to provide GTI services.

Go to Table of Contents