title: Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria.
abstract: BACKGROUND
  Contraceptive use remains low in Nigeria, with only 11% of women reporting use of any modern method. Access to long-acting reversible contraceptives (LARCs) is constrained by a severe shortage of human resources. To assess feasibility of task shifting provision of implants, we trained community health extension workers (CHEWs) to insert and remove contraceptive implants in rural communities of Bauchi and Sokoto states in northern Nigeria.
  
  
  METHODS
  We conducted 2- to 3-week training sessions for 166 selected CHEWs from 82 facilities in Sokoto state (September 2013) and 84 health facilities in Bauchi state (December 2013). To assess feasibility of the task shifting approach, we conducted operations research using a pretest-posttest design using multiple sources of information, including surveys with 151 trained CHEWs (9% were lost to follow-up) and with 150 family planning clients; facility observations using supply checklists (N = 149); direct observation of counseling provided by CHEWs (N = 144) and of their clinical (N = 113) skills; as well as a review of service statistics (N = 151 health facilities). The endline assessment was conducted 6 months after the training in each state.
  
  
  RESULTS
  CHEWs inserted a total of 3,588 implants in 151 health facilities over a period of 6 months, generating 10,088 couple-years of protection (CYP). After practicing on anatomic arm models, most CHEWs achieved competency in implant insertions after insertions with 4-5 actual clients. Clinical observations revealed that CHEWs performed implant insertion tasks correctly 90% of the time or more for nearly all checklist items. The amount of information that CHEWs provided clients increased between baseline and endline, and over 95% of surveyed clients reported being satisfied with CHEWs' services in both surveys. The study found that supervisors not only observed and corrected insertion skills, as needed, during supervisory visits but also encouraged CHEWs to conduct more community mobilization to generate client demand, thereby promoting access to quality services. CHEWs identified a lack of demand in the communities as the major barrier for providing services.
  
  
  CONCLUSIONS
  With adequate training and supportive supervision, CHEWs in northern Nigeria can provide high-quality implant insertion services. If more CHEWs are trained to provide implants and greater community outreach is conducted to generate demand, uptake of LARCs in Nigeria may increase.
authors.affiliation: Palladium, Washington, DC, USA Zulfiya.Charyeva@thepalladiumgroup.com.
authors.forename: Zulfiya
authors.initials: Z
authors.lastname: Charyeva
authors.affiliation: Palladium, Washington, DC, USA Targeted States High Impact Project (TSHIP), Bauchi, Nigeria.
authors.forename: Olugbenga
authors.initials: O
authors.lastname: Oguntunde
authors.affiliation: Targeted States High Impact Project (TSHIP), Bauchi, Nigeria JSI Research & Training Institute, Arlington, VA, USA.
authors.forename: Nosa
authors.initials: N
authors.lastname: Orobaton
authors.affiliation: Targeted States High Impact Project (TSHIP), Bauchi, Nigeria Jhpiego - an affiliate of Johns Hopkins University, Abuja, Nigeria.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Otolorin
authors.affiliation: Targeted States High Impact Project (TSHIP), Bauchi, Nigeria Jhpiego - an affiliate of Johns Hopkins University, Abuja, Nigeria.
authors.forename: Fatima
authors.initials: F
authors.lastname: Inuwa
authors.affiliation: Targeted States High Impact Project (TSHIP), Bauchi, Nigeria Jhpiego - an affiliate of Johns Hopkins University, Abuja, Nigeria.
authors.forename: Olubisi
authors.initials: O
authors.lastname: Alalade
authors.affiliation: Targeted States High Impact Project (TSHIP), Bauchi, Nigeria JSI Research & Training Institute, Arlington, VA, USA.
authors.forename: Dele
authors.initials: D
authors.lastname: Abegunde
authors.affiliation: Palladium, Washington, DC, USA Targeted States High Impact Project (TSHIP), Bauchi, Nigeria.
authors.forename: Saba'atu
authors.initials: S
authors.lastname: Danladi
mesh_terms: D003153:Community Health Services / Q000379:methods*; D003150:Community Health Workers; D003268:Contraception Behavior; D003271:Contraceptive Agents, Female / Q000008:administration & dosage*; D005193:Family Planning Services / Q000379:methods*; D005260:Female; D006801:Humans; D009549:Nigeria; D009874:Operations Research; D012424:Rural Population
chemical_list: D003271:Contraceptive Agents, Female