Assessing the barriers and enablers of on-the-job provider training for subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in the public sector in Ghana: a cross-sectional mixed-methods study

Subcutaneous depot-medroxyprogesterone acetate is an injectable contraceptive that can be administered by any trained person, including for self-injection. When rolling out in-service provider training on subcutaneous depot-medroxyprogesterone acetate between 2019 and 2021, Ghana Health Service tasked a cohort of formally classroom-trained providers to provide on-the-job training to colleagues to cost-effectively improve training coverage. This cross-sectional mixed-methods study assessed the barriers and enablers of this approach. The study was conducted in 2021 and included a structured quantitative survey of providers (n=192) across trained facilities in four regions in Ghana, plus key informant interviews with regional resource team members (n=8), facility in-charges (n=8), and formally-trained or on-the-job trained providers (n=16). Descriptive statistics and Chi-2 tests were used to compare quantitative outcomes between formally-trained and on-the-job trained providers in survey data. Qualitative results were analysed thematically and triangulated with quantitative results. Most participants reported that on-the-job training had been inconsistently implemented. Where implemented, on-the-job training was reported to vary in length and depth, with on-the-job trained providers typically reporting fewer training components than formally-trained providers. Contemporary challenges around stock availability affected providers motivation to prioritize on-the-job training. Formally-trained providers were more satisfied with training than on-the-job trained providers (98.1% versus 50.6%, p<0.05). Both cohorts scored comparably in injectables counselling role-plays and demonstrated comparable attitudes towards injectables. However, formally-trained providers scored better in recall of the five critical self-injection steps (65.4% and 37.9%, p<0.01). Post-training supervision was highly valued but inconsistently implemented. Regional resource team members and facility in-charges recommended more supervision to standardise on-the-job training and address residual knowledge gaps. This study found that, when inconsistently implemented, on-the-job training led to variations in provider satisfaction with training and provider skill to counsel on subcutaneous depot-medroxyprogesterone acetate, particularly for self-injection. The authors recommended standardizing on-the-job training and increasing supportive supervision to optimize the model.