Jhpiego TR Executive Summary - A Self-Paced Learning Package for Training in the No-Scalpel Vasectomy Technique: The Experiences of Trainers and Participants in Nepal

Since 1968, when the first vasectomy procedures were performed in Nepal, vasectomy has become an important component of the Nepal family planning (FP) program. In the early 1990s, providers began using the no-scalpel vasectomy (NSV) technique, and in 1994, the NSV technique was formally incorporated into the Nepal FP program. Most training in NSV was done using a group-based training approach. NSV trainers, however, had difficulty accommodating group-based training demands because of their competing responsibilities as FP healthcare providers at their respective sites. In addition, because of the limited vasectomy caseload during training, a training site can only have one to two participants at a time for NSV training. To address these challenges, in 1999 Jhpiego and the National Health Training Center (NHTC) introduced a self-paced learning package for NSV designed to lessen the amount of time NSV trainers needed to conduct training so they could maintain their clinical responsibilities. The self-paced learning package consisted of a guided, self-paced training module with a manual and associated audiovisual aids. From 1999 to 2000, 30 NSV providers were trained using the self-paced learning approach. Jhpiego and the NHTC conducted an evaluation from December 2000 to April 2001 to document the experience of trainers and participants with the self-paced learning approach for NSV, and to assess the job performance of these trained providers.

The sample consisted of healthcare providers trained in courses conducted from September 1999 to March 2000 (n=27) and all NSV trainers (n=6) from three training centers. The evaluation team contacted healthcare providers by telephone to conduct interviews. Nine providers were observed conducting the NSV procedure, and 5 of these providers were observed at their posts where the supplies and equipment were also assessed. Trainers were given structured self-administered questionnaires to complete and then were briefly interviewed.

Most participants (26) characterized the training as "very effective." Five of the 6 trainers said the self-paced learning approach was "very effective" in transferring knowledge and skills. Four of the 5 trainers with previous NSV group-based training experience said the self-paced training approach for NSV was more effective than the group-based approach, while 1 trainer characterized them as equally effective.

Trainers reported reduced training time to be a major advantage of the self-paced learning approach. Trainers and participants indicated that the practical and clinical skills of the self-paced learning package were important elements of the training. Five of the 6 trainers, however, said that some participants were "not comfortable with learning on their own," and some of the participants (22%) expressed a lack of comfort as well.

Thirteen of the participants and 4 of the trainers felt that the recommended duration of the training (17 days) was appropriate, but those with a Doctor of Medicine (MD) or Master of Surgery (MS) qualification were more inclined to recommend shortening the course. Participants with previous vasectomy experience or with a MD or MS needed less time on the knowledge portion as compared to those without these qualifications. Participants needed between 3 to 11 days of supervised NSV procedures before they were assessed as competent. Those with previous vasectomy experience required less time (3 to 8 days) compared to those without previous vasectomy experience. Participants reported that they conducted 2 to 4 NSV cases per day during the clinical practice portion of the training. When trainers were asked how many cases were required for participants to reach competency, 2 said 3 to 7 cases, 3 said 10 to 15 cases, and 1 said 20 cases.

A key finding was that most of the trainers (5 of 6) said they were able to fulfill their clinical duties adequately while conducting self-paced training. Participants reported they received a mean of 2 hours per day with the trainer, although they felt they needed 3 hours.

After training, 18 of the 27 participants reported providing NSV services at post, and 11 of the 18 had provided services at FP field camps. The number of cases performed ranged from fewer than 20 (5 participants) to more than 100 (9 participants). Participants reported that a caseload of fewer than 20 was insufficient to retain their skills. Providers with lower caseloads were more likely to report wanting refresher courses. Fewer MD or MS graduates felt they needed support as compared to the participants with other qualifications.

The evaluation team found that 5 of the 9 NSV self-paced training participants observed were competent in all 16 critical steps on the NSV observation checklist-two of whom had not provided any NSV services since returning to post. Postoperative infection prevention practices were very good as well. Three of the providers observed did not have any NSV sets at their posts and thus were unable to provide services.

Several recommendations emerged from this evaluation:

Because self-paced learning was a relatively new idea to most of the participants in the study, participants should be provided with a short, introductory session on methods for self-learning at the onset of training.

Trainings should be scheduled for the early part of the winter season (from October to January) to provide a higher caseload for participants.

A sufficient number of NSV sets needs to be distributed to participants at the end of training (through the Family Health Division).

Participants with previous vasectomy experience and MD or MS qualifications should attend shorter training courses.

From September 1999 to March 2000, self-paced learning was the only means used for training NSV providers in Nepal, during which time 30 NSV providers were trained to competency in the procedure. One year after training, 27 participants were followed up for this assessment, with two-thirds of them reporting having provided the procedure. Although only 13 of those 18 participants consider their current caseload to be sufficient to maintain the skills they acquired, all have expressed confidence in the self-paced training method. This assessment documents the success of the self-paced learning approach to NSV, and the recommendations made above will strengthen the approach in the future.