Impact of the hands-on clinical training program for subdermic implant on contraceptive counseling and users' choice in Spain: A 6-month follow-up study

Contents lists available at ScienceDirect Contraception journal homepage: www.elsevier.com/locate/contraception Impact of the hands-on clinical training program for subdermic implant on contraceptive counseling and users’ choice in Spain: A 6-month follow-up study ☆,☆☆ Fatima Leon-Larios a,⁎ , Maria Jesus Alonso Llamazares b , Hildegard Mausbach Reisen c , Inmaculada Parra Ribes d , Modesto Rey Novoa e , Isabel Lahoz-Pascual f a Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Facultad de Enfermería, Fisioterapia y Podología, Sevilla, España b Unidad de Salud Sexual y Reproductiva, Distrito Sanitario Málaga-Guadalhorce, Servicio Andaluz de Salud, Málaga, España c Centre d′atenció a la salut sexual i reproductiva ASSIR El Maresme, Mataró, Barcelona, España d Centro de Salud de Sueca, Valencia, España e Departamento de Obstetricia y Ginecología, Complejo Asistencial Universitario de Burgos, Burgos, España f Departamento de Obstetricia y Ginecología, Hospital Universitario Lozano Blesa, Zaragoza, España article info Article history: Received 4 September 2023 Received in revised form 10 January 2024 Accepted 11 January 2024 Keywords: Clinical training program Contraception counseling Implants Long-acting reversible contraception Postgraduated education abstract Objectives: The study aimed to evaluate the impact of a structured subdermic implant training program on healthcare providers and its effect on the integration of this contraceptive method into patient counselling. Study design: The study was a longitudinal experiment with an intervention group, assessing changes at three points: before the training, immediately after, and six months later. The training consisted of a fourhour session combining theory and practical application, conducted by experts in contraception. Results: Out of the participants, 376 healthcare professionals (a 34.3% response rate) completed the training and subsequent questionnaires. Post-training, there was an increase in the inclusion of the implant in contraceptive advice and a rise in the monthly number of implants. Knowledge about the implant, including insertion, positioning, removal, and replacement, significantly improved after six months (p < 0.05), particularly among general practitioners. Conclusions: The training program successfully enhanced knowledge and handling of the contraceptive implant, leading to its increased recommendation by healthcare providers and selection by patients. Theoretical and practical training in contraception should be compulsory for healthcare providers involved in contraceptive counselling. Implications: A training program that includes lectures, video material, and hands-on demonstrations is effective for developing skills in administering the subdermic implant and its integration into contraceptive counselling. Such training should be regular and required for all healthcare professionals providing contraceptive advice. © 2024 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). 1. Introduction Unintended pregnancies still outnumber desired ones, both in Spain [1] and at the global level [2]. Although access to contraceptive methods is guaranteed by the Spanish Public Health System, 24.9% of the patients do not use any method, exposing themselves to unintended pregnancies [3]. Long-acting reversible contraceptives (LARCs) are considered a safe and reliable contraception option and more economical to prevent unplanned pregnancies than short-acting reversible contraceptives [4]; however, their use among the population of reproductive age continues to be low [1, 5, 6]. According to the data published from the National Contraception Survey conducted by the Spanish Contraception Society, the most used contraceptive methods among patients aged 15 to 49 years continue to be condoms and pills, and the use percentage of LARCs is below 10% [1,7]. Among the reasons identified for low LARC usage are disinformation and erroneous beliefs, both in health professionals and in Contraception 132 (2024) 110372 https://doi.org/10.1016/j.contraception.2024.110372 0010-7824/© 2024 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ☆ Conflicts of interest: The authors declare that they have no competing interests. ☆☆ Funding: No funding source was involved in study design, data collection, analysis and interpretation, and writing or submission of this paper. The opinions expressed in this paper are those of the authors and do not necessarily reflect stances or policies of the Spanish Contraception Society. ]]]] ]]]]]] ⁎ Corresponding author. E-mail address: [email protected] (F. Leon-Larios). patients [8]. Duly qualified professionals trained in contraceptive methods usually provide better quality contraceptive counseling, contributing to reducing the number of unplanned pregnancies [9]. When health professionals have sound knowledge about LARCs and undergo training on their handling, their use among patients is increased [2,10]. The objective of this study was to assess the impact of a structured training session about the subdermic implant on health professionals and its influence on the incorporation into contraceptive counseling and choice by patients and their partners. 2. Materials and methods 2.1. Design The study, conducted between 2019 and 2021, evaluated a clinical training program (CTP) focused on the hands-on application of contraceptive implant techniques. 2.2. Measures A comprehensive online questionnaire assessed participants’ sociodemographic details, professional experience, motivation for training, patient interaction frequency, and self-perceived proficiency in implant counseling and procedures at three intervals: baseline, immediately after training, and 6 months post-CTP. 2.3. Intervention: CTP The CTP, using simulators for practice, imparted skills to handle the subdermic implant (Implanon NXT, N.V. Organon, OSS, the Netherlands). It was crafted from the collective expertise of health professionals and supported by the relevant literature [2,11]. The trainers, skilled in contraception and implant procedures, conducted sessions capped at 15 participants to ensure personalized attention. The intervention spanned 4 hours, beginning with a theoretical overview of the implant and progressing to hands-on training with a placebo implant on a simulated arm, emphasizing the inclusion of the implant in contraceptive counseling. 2.4. Eligibility criteria Participants included gynecologists, general practitioners, and midwives from 15 Spanish regions, engaged in contraceptive counseling and interested in performing implant insertions. Recruitment was through the Spanish Society of Contraception, with only those completing all three evaluations included in the study. 2.5. Statistical analyses The study employed the Kolmogorov-Smirnov test for numerical variables, the χ 2 test for qualitative data, and nonparametric tests for analysis. A repeated cross-sectional method assessed the program’s impact, analyzing the data with SPSS version 24.0 for Windows (IBM Corp, Armonk, NY)), with significance noted at p < 0.05. 2.6. Ethical considerations Participation was voluntary and anonymous, with no financial incentives. Data privacy was maintained according to the Data Protection Law, and access to information was restricted to the research team. 3. Results A total of 1070 professionals enrolled in the CTP by the Spanish Contraceptive Society to learn subcutaneous implant procedures, with 367 completing the training and follow-ups, yielding a 34.3% response rate. As Table 1 presents, most participants were female, aged < 35 years, working in the public sector, and regularly offering contraceptive counseling, averaging one to two implant procedures monthly. The group was evenly split between gynecologists/general practitioners/residents and nurses/midwives/residents. Professionals sought to enhance both theoretical and practical skills in implant procedures (61%), to learn about these procedures (15%), or to gain a comprehensive understanding of the implant (14.4%). As seen in Figure 1, participants’ self-assessment showed improved knowledge and competence in offering counseling and locating implants posttraining, but they felt less adept in removal and replacement, though these skills improved over time. As pointed out in Table 2, 6 months after the CTP, nearly half of the participants had started inserting implants. There was an increase in the number of implants inserted (30.5% baseline vs 52% after) and removed (29.4% baseline vs 38.4% after). Overall, 98.3% valued the training highly, and 71.8% felt qualified to train others. Table 3 (supplementary file) presents the evolution of knowledge and skills in handling the implant by profession. Gynecologists were the most proficient in posttraining implant procedures, with family physicians initially improving but experiencing a decline in skills after 6 months. However, all professionals, except gynecologists, reported a decrease in competence over time. The study found no significant gender or age differences in skill acquisition. 4. Discussion This study aimed to measure the effectiveness of a combined theoretical and practical training program on Spanish health professionals’ skills in inserting, locating, removing, and replacing contraceptive implants. The program’s impact was significant, with professionals showing increased competence in implant procedures Table 1 Sociodemographic characteristics of the clinical training program participants in Spain Variables Categories n % Age < 25 11 3.0 25–35 217 59.1 36–45 77 21.0 46–55 36 9.8 > 55 26 7.1 Gender Female 321 87.5 Male 46 12.5 Participant’s profession Midwife intern 36 9.8 Midwife/nurse 165 45.0 Medical intern 101 27.5 Family physician 22 6.0 Gynecologist 43 11.7 Professional activity Public 330 89.9 Private 11 3.0 Public and private 26 7.1 Provide contraceptive counseling in current role Yes 306 84.2 No 58 15.8 Average number of implants inserted None 255 69.5 1–2 per month 60 16.3 3–5 per month 26 7.1 6–9 per month 16 4.4 ≥10 10 2.7 Average number of implants removed None 259 70.6 1–2 per month 68 18.5 3–5 per month 23 6.3 6–9 per month 10 2.7 ≥10 7 1.9 F. Leon-Larios, M.J. Alonso Llamazares, H. Mausbach Reisen et al. Contraception 132 (2024) 110372 2 both immediately and 6 months following the CTP, consistent with research from Brazil [5] and the United States [2]. Evidence suggests that in-depth knowledge of contraceptive methods, obtained through comprehensive training, enhances their application among both health professionals and the general population [10,12]. The CTP’s face-to-face component was crucial for developing realistic skills, surpassing online-only training approaches [11,13]. Hands-on training sessions are vital for skill acquisition and resolving uncertainties, usually receiving positive feedback for improving clinical competencies [12, 14, 15]. The study found that participants’ confidence and ability to handle the implant and its applicator increased after attending the CTP and remained higher 6 months later [16]. While insertion was considered easier and thus had higher self-reported competence, removal was less practiced, though confidence in both increased with experience [17,18]. Interestingly, family physicians reported the most significant improvement 6 months posttraining, despite starting with lower baseline skills compared to gynecologists, who consistently showed high competence [19]. The training also led to more frequent inclusion of the implant in contraceptive counseling and influenced patient choices, echoing the outcomes of similar interventions [2,10]. A decline in reported competence was noted at the 6-month mark compared to the period immediately after the CTP, but the skills level remained above pretraining levels. This suggests that continual training could mitigate the natural decline of knowledge over time [10]. While no 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% baseImm 6m baseImm 6m base Imm 6m base Imm 6m base Imm 6m baseImm 6m Counsel the user Handle the preload applicator Insert implant Locate implant Remove implant Replace implant Not at all qualified Somewhat qualified Sufficiently qualified Totally qualified Fig. 1. Qualification level acknowledged in various aspects for all three questionnaires (in percentages values). 6m = 6 months after training; base = baseline; Imm = immediate after training. Table 2 Experiences with the contraceptive implant 6 mo after the clinical training program in Spain Variables Categories Baseline, n (%) 6 mo, n (%) Number of implants inserted per month None 255 (69.5) 176 (48) Between 1 and 2 60 (16.3) 127 (34.6) Between 3 and 5 26 (7.1) 35 (9.5) Between 6 and 9 16 (4.4) 18 (4.9) Between 10 and 20 2 (0.5) 9 (2.5) > 20 8 (2.2) 2 (0.5) Number of implants removed per month None 259 (70.6) 226 (61.6) Between 1 and 2 68 (18.5) 105 (28.5) Between 3 and 5 23 (6.3) 23 (6.3) Between 6 and 9 10 (2.7) 12 (3.3) Between 10 and 20 7 (1.9) 1 (0.3) Has inserted implants after the training Yes 183(49.9) No 184(50.1) Has offered implants more than before Yes 268 (73) No 99(27) Importance of having finished the training Not at all important 0 (0) A little important 6 (1.6) Important 126 (34.3) Very important 235 (64) Importance of having a certificate of their qualification Not at all important 2 (0.5) A little important 21 (5.7) Important 152 (41.4) Very important 192 (52.3) Has consulted the trainer Yes 104 (28.3) No 263 (71.7) The consultation has been satisfactory Yes 104 (100) No 0 Reason for the consultation Has not inserted any implant 112 (44.1) Solved it by him/herself 73 (28.7) Solved it with the help of his/her environment 36 (14.2) Had no contact data 7 (2.8) Unaware of the consultation option 26 (10.2) Considers him/herself qualified to train others Not at all qualified 11.8 43 (11.8) Somewhat qualified 16.4 60 (16.4) Sufficiently qualified 50.4 184 (50.4) Totally qualified 21.4 78 (21.4) F. Leon-Larios, M.J. Alonso Llamazares, H. Mausbach Reisen et al. Contraception 132 (2024) 110372 3 specific studies define the optimal frequency for such training, research in obstetric emergencies indicates that knowledge retention wanes after a year, recommending refresher sessions every 6 months [20]. The study’s strength lies in its multicentric approach, covering a broad geographic area of Spain. However, it is limited by the selfreported nature of the data, which does not allow for the direct verification of the acquired skills in implant procedures or applicator use. Training on how to handle the subdermic implant increased its inclusion in contraceptive counseling and its use among patients; therefore, theoretical-practical structured training is recommended for all health professionals involved in family planning to enhance knowledge, reduce myths, and improve handling of the implant. Furthermore, it would be convenient to repeat the training annually as dexterity decreases with the passage of time. Author contributions All authors conceived the original research topic, and all authors designed this study within the specific context. All authors were involved in recruiting participants and collecting data. F.L.L. was involved in procedures of data analysis and interpretation. The first draft of the manuscript was written by F.L.L. and significantly revised by all authors. All remaining authors commented on the revisions of the paper. All authors gave their final approval for this version to be submitted and published. Acknowledgments The authors are grateful to Organon for providing the devices for the training. The authors would like to thank the Spanish Contraception Society for their support in providing this accredited course to health care providers throughout Spain. 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