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.

The authors have declared no competing interest.

This work was supported, in whole or in part, by the Gates Foundation [Opportunity ID: OPP1195232]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The conclusions and opinions expressed in this work are those of the author(s) alone and shall not be attributed to the Foundation. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study was conducted in line with the principles outlined in the Declaration of Helsinki. The study team worked closely with the study regions, districts and facilities through the office of the Ghana Health Service Director General to secure appropriate approvals. The study protocol and tools were approved by GHS Ethics Review Committee in Accra, Ghana, a board that is also registered as an International Institutional Review Board with Federal Wide Assurance (IRB: IRB00009260, FWA00020025), study protocol approval number GHS-ERC: 019/08/21. All participants provided written informed consent to participate in the survey and key informant interviews.

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The data collection tools, anonymised qualitative code reports (coded qualitative excerpts against relevant themes) and the anonymised provider survey dataset behind the findings and conclusions of this paper are available via https://doi.org/10.5281/zenodo.15545267 The qualitative code reports have been provided rather than full in-depth interview transcripts due to concerns about narrative descriptions and contextual references in the full qualitative transcripts making participants possibly indirectly re-identifiable. Qualitative analysis can still be re-created using the code reports provided.

https://doi.org/10.5281/zenodo.15545267