Expanding contraceptive method choice, including introducing new contraceptive technologies to health markets, is a critical step in addressing unmet need for family planning. Introduction of new technologies is not without challenge, particularly in low- and middle-income country (LMIC) settings ¹ . The hormonal intrauterine device (IUD), a highly effective long-acting reversible contraceptive method (LARC), has been largely unavailable in sub-Saharan Africa (SSA) as a result of initial high cost of the product, poor understanding of demand for the method, and lack of awareness of the method ^{2, 3} . Following years of collaborative effort among a consortium of global stakeholders, the method was added to the procurement catalogs for the U.S. Agency for International Development (USAID) and the United Nations Population Fund (UNFPA) in 2021 ³ . This, combined with a price reduction of quality-assured hormonal IUD products, led to increased availability of hormonal IUD in LMICs. Several countries in SSA, including Nigeria, are poised to introduce the method on a wider scale ⁴ .

Prior to 2019, Nigeria’s efforts to expand access to LARCs were focused on scaling up implants and copper IUD. Since then, Nigeria’s Federal Ministry of Health (FMOH) developed and launched the National Hormonal Intrauterine Device Introduction and Scale-up plan ⁵ , a costed implementation plan that outlines policy support and procurement, national training plans with competency assessments, and systems for national scale up. In 2022, implementation of this plan is underway, with quantification of the method for public sector use and training for health care providers. The FMOH and their global partners are exploring efficient and effective approaches to make the strategy a reality and scale up the hormonal IUD. This includes training approaches.

Restrictions during the COVID-19 pandemic disrupted traditional trainings but also opened the door to new approaches, including digital learning. The “new normal” for training approaches, following the COVID-19 pandemic, increasingly includes use of remote technologies ⁶ . As digital technologies are introduced into clinical training, corresponding means of assessing clinical competencies must be developed. This study measured competence using an Objective Structured Clinical Examination (OSCE).

The OSCE approach to assessing skills was introduced by Harden in 1975 ^{7, 8} , and has been used widely in health sciences and medical education for certification, licensure and in various assessment settings ⁹ . In LMICs, OSCE has been used widely in in-service training, particularly with Helping Babies Breathe ¹⁰ , a training model which aims to improve health care provider skills in providing resuscitation to asphyxiated newborns. In Nigeria, OSCE has been integrated into training assessments for medical students and postgraduate medical doctor trainees in various medical training programs. There is a strong literature base discussing the strengths and drawbacks of applications of OSCE in medical education in Nigeria ^{11– 16} . While multiple studies exist which look at the use of remote applications of OSCE ^{17– 19} , little has been written on the use of OSCE integration into digital training courses, either for hormonal IUD or more broadly.

A study of a hybrid digital and in-person training for hormonal IUD services for health care providers experienced in copper IUD provision was conducted in Nigeria from April to December 2021 (publication under review). The study evaluated feasibility, acceptability, competency, and knowledge gains of health care providers taking the training package. The current article describes the experience of using OSCE as part of the training model. This paper will be useful to policy-makers and program implementers in Nigeria and similar settings who are either planning training programs for hormonal IUD, or considering competency assessment approaches within design of digital training or hybrid digital / in-person training.

This study was reviewed by FHI 360’s Office of International Research and Ethics (OIRE) and determined exempt (1735182-1). The study was also reviewed by the National Health Research Committee of Nigeria (NHREC) and was approved (NHREC/01/01/2007-03/06/2021). Written informed consent was obtained from all study participants before enrollment in the study, for use of OSCE scores.

A total of 62 health care providers from Enugu, Kano and Oyo States completed the digital didactic training and took part in the OSCEs. Out of 62 participating trainees, all 62 consented to having their OSCE scores used for research purposes and 60 consented to having demographic information used. Of the 60 trainees whose OSCE scores are presented, 50% were nurses; 33% were midwives; 12% were community health workers and 5% were doctors ( Table 1). The trainees also represented both private and public sectors: 60% of the health care providers were employed in the public sector, 25% in the private sector, and 15% in both public and private sector facilities.

While digital trainings may be a cost-effective option for health care providers in LMICs, there is limited evidence about the effectiveness, feasibility, and impact of the training on both health systems and at the individual level ²¹ . This study assessed competency scores following a hybrid digital / in-person training that aimed to expand high-quality hormonal IUD services in Nigeria. In the process of looking at competency scores and processes associated with using OSCE as a research assessment methodology, we gained useful insight into the overall training model and process, some of which is unique to hormonal IUD.

For purposes of the pilot study described here, OSCE was included. However, the training model evaluated, which has been endorsed by the FMOH to be included in national scale up of hormonal IUD in Nigeria ⁵ , uses supervised provision of service rather than OSCE to establish competency, for both cost savings and training efficiency reasons. With the group enrolled in the study (health care providers who had previous experience in providing copper IUDs group), it would have been surprising to see low level of competency in provision of hormonal IUD services, particularly insertions and removals, since those skills do not vary between the hormonal and copper IUD. Given extremely high competency seen among these experienced providers, OSCE as a competency assessment approach may not be necessary in the non-research (i.e. training rollout) context. The experienced background of the trainees in IUD service provision may explain differences between the findings in this study and one which assessed provider skills in nine countries in sub Saharan Africa and Asia following training on obstetric skills, which documented higher skills gains using the OSCE assessment (23 – 35%) ²² . An outstanding question is whether the OSCE would serve as an important training component by identifying providers not yet sufficiently skilled in hormonal IUD services among inexperienced providers. If hormonal IUD services are to be scaled up to include providers who are not already trained and experienced in providing LARCs, there is a strong argument for vetting skills using OSCE before trainees proceed to supervised service provision.

While digital trainings may save time and resources compared to didactic classroom-based elements, clinical trainings, including hormonal IUD training, will generally benefit from some in-person components. There is precedent for including OSCE as a training approach to improve the hormonal IUD training model: OSCE is a proven approach to both teaching and evaluation of competency ^{8, 9} . In Nigeria, OSCE has shown to compare favorably with other assessment methodologies for medical students ^{12, 13, 15, 16} . In the United States, standardized patients at OSCE stations have been used to assess resident doctors’ ability to counsel vaccine-hesitant patients ²³ , and medical students’ ability to counsel patients with obesity ²⁴ . OSCE has been used to improve communication, interpersonal and counseling skills ²⁵ . Future training models for hormonal IUD scale up may want to explore use of OSCE as a training tool rather than (or in addition to) as an assessment tool. Building competency may be even more important in the context of digital training where trainers lack the ability to interact with trainees face-to-face to get a sense of their communication skills and fluency with the content. Additionally, there may be applications for assessing retention of health care providers’ skills and knowledge over time, and the acquisition of skills and knowledge among a larger pool of providers as hormonal IUD is scaled up in Nigeria.

As training for hormonal IUD expands in Nigeria and globally, future studies may want to measure outcomes of training, rather than the focus on model which guided the current study. In Ghana, Kenya, and India, for example, perinatal mortality was tracked following Helping Babies Breathe training ^{26, 27} . An evaluation of the hybrid digital / in-person training model should ideally include outcomes, such as post-training behavior of health care providers, or provision of hormonal IUD services where health care providers were trained ²⁸ . A focus on outcomes moves the training further along the levels described by Kirkpatrick’s model for evaluation of training programs, from Reaction and Learning to Behavior and Results ²⁹ .

This study had some limitations. A specific limitation of the OSCE approach was that the stations were not timed, which may have resulted in higher scores than would have otherwise been seen. Further, no baseline OSCE was performed to assess changes in clinical performance as a result of the training. Additionally, generalizability is limited due to the small number of health care providers trained and the purposive selection of the three states.

This study presents findings from OSCE assessment in a study of a digital / in-person training model for hormonal IUD in Nigeria. The uniformly high scores of these experienced LARC providers in the study makes it questionable whether OSCE should be incorporated into a scaled-up training model. However, if the training is extended to include “LARC-inexperienced” health care providers, the OSCE assessment may become important as a means to assess competency before trainees provide supervised services to clients. Future evaluations would be helpful in investigating the role of OSCE in training for health care providers who are inexperienced at providing LARCs. Finally, future studies on digital or hybrid digital / in-person training should look to incorporate outcomes of training into design, to further the agenda of transforming training into outcomes and impacts for those we are trying to reach with contraceptive technologies.