Consistency of on-the-job training implementation for subcutaneous depot medroxyprogesterone acetate in Ghana and associated healthcare worker knowledge transfer: A cross-sectional mixed-methods study

Subcutaneous depot medroxyprogesterone acetate, or DMPA-SC, is an injectable contraceptive that can be administered by any trained person, including for self-injection. When scaling in-service healthcare worker training on DMPA-SC between 2019 and 2021, Ghana Health Service tasked a cohort of formally-trained healthcare workers to transfer their training 'on-the-job' to colleagues at their facilities, to save costs while improving training coverage. This cross-sectional mixed-methods implementation study explored the consistency of this approach in practice and how healthcare worker knowledge of DMPA-SC differed between healthcare workers receiving formal and on-the-job training. The study, conducted in 2021, included a structured survey of healthcare workers (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 healthcare workers (n = 16). Descriptive statistics, equality-of-proportions tests, and logistic regressions (adjusting for clustering by facility) were used to compare quantitative outcomes between formally-trained and on-the-job trained healthcare workers. Qualitative results were analysed thematically and triangulated with quantitative results. Only 62% of eligible healthcare workers surveyed reported receiving any on-the-job training on DMPA-SC from a formally-trained colleague. Where implemented, on-the-job training was reported to vary in length and depth, with on-the-job trained healthcare workers typically reporting fewer training components and lower satisfaction with training than formally-trained counterparts. Both cohorts scored comparably in injectables counselling role-plays and demonstrated comparable attitudes towards injectables. However, formally-trained healthcare workers scored better in overall correct knowledge of DMPA-SC (59.6% versus 26.4%, aOR: 4.68, 95%CI: 1.98-11.07, p < 0.01) and recall of all five critical self-injection steps (65.4% versus 37.9%, aOR 3.52, 95%CI: 1.53-8.10 p < 0.01). This study found that on-the-job training had been inconsistently implemented, seemingly leading to incomplete knowledge transfer on DMPA-SC between healthcare workers. The authors recommended standardising on-the-job training and increasing supportive supervision to strengthen the approach.