The newly developed S-CORT curriculum on uterine evacuation integrating manual vacuum aspiration and medication techniques was implemented in fragile or humanitarian contexts in Uganda, Nigeria, and the DRC. Results from the three workshops converged to suggest that the module contributed to increasing participants’ theoretical knowledge, technical and counseling skills, confidence, and positive attitudinal changes that promote a rights-based, fearless, non-judgmental, and non-discriminatory approach toward clients. Participants valued the hands-on, humanistic, and competency-based training methodology, although most regretted the short training duration.
We can draw several lessons to improve this S-CORT curriculum and the overall model as well as inform the design and implementation of new training curricula aimed at refreshing the knowledge and skills of service providers working in humanitarian settings.
First, this triple evaluation aligns with previous research on the S-CORT model, which suggests that the approach is respectful of human rights and quality of care principles in addition to being potentially effective in enhancing the knowledge and skills of existing trained service providers, strengthening their capacity, and changing their attitudes [15].
Combining medication uterine evacuation with manual vacuum aspiration within the same curriculum appeared feasible and indeed complementary as misoprostol and mifepristone are increasingly available in countries affected by fragility or crises [32, 33]. Additionally, universal access to such medications, which are part of the WHO Model List of Essential Medicines [34], adhere to contemporary standards on sexual and reproductive health and rights [35].
Second, it is important to remember the S-CORT capacity development strategy: a rapid on-the-ground training during the acute or post-acute phase of a crisis to refresh the knowledge and skills of service providers on a specific lifesaving intervention, which they learned in the past. However, all three workshops, although implemented in fragile or humanitarian contexts, did not occur in acute crisis settings, and many of the participants did not have former training on uterine evacuation. Therefore, humanitarian coordinators should be considerate of the operational context, available resources, and profiles and needs of participants when planning for an extension beyond the two-day core training. For instance, adding an extra day for values clarification and attitude transformation is a best practice in uterine evacuation programming and should be a prerequisite if not done previously. However, the S-CORT curriculum already covers the topic in a condensed session. For those without prior exposure to uterine evacuation, a more comprehensive workshop over five or more days with ample opportunities for hands-on and clinical practice would better meet their training needs. For the training to be both effective and efficient, participants should be screened in advance and training materials adapted to ensure the course is the most appropriate to meet their learning needs, background, and professional objectives [36].
Third, evaluating programs in unstable and resource-limited settings raises the question of balancing feasibility with validity [37]. The evaluation of our pilots had the merit of adopting a multi-pronged approach to shed light on changes in knowledge (pre-test and post-test), participants’ and trainers’ experience and perspectives (qualitative methods), and the strengthening of competencies (competency checklists). Our experience speaks against using competency checklists as a training program evaluation tool but illustrates the usefulness and feasibility of a mixed-method approach using qualitative interviews. These interviews provided nuances to the results of the written tests by exploring important skill retention factors, such as attitudinal changes or confidence [38]. Competency-based training requires a checklist to systematically record the status and progress for each step of the clinical competency to be acquired. There were 63 steps for medication uterine evacuation and 78 for manual vacuum aspiration. Collecting and cleaning this vast amount of data for each participant once before and once after training was a daunting task, which we underestimated. The checklist forms collected from all three workshops showed considerable incompleteness and inconsistencies, which did not allow us to exploit the data. Therefore, competency-based checklists should be used less as a reporting tool but more as a support to build trainees’ competencies. In this respect, it is critical for facilitators to clearly explain how to use the checklist and verify that trainees do so correctly and systematically to evaluate one another reliably. Such a checklist has the added value of serving as an ongoing training job aid for providers to rehearse and boost their clinical skills periodically after the training [39].
Regarding knowledge testing, the increase of the average post-test score across countries and the rise by 25 percentage points among a few participants suggested that the curriculum could be overall effective in enhancing knowledge. In Uganda, the average pre-test score of 84% with a modest post-test increase of 5 percentage points may be due to the overall high level of knowledge of a relatively homogeneous group of service providers. In contrast, the Nigerian participants scored on average lower and had a modest post-test increase. With a third of participants having a lower post-test score, the overall performance in Nigeria could have been affected by the inadequate mix of community health extension workers with other providers as well as post-workshop fatigue and reporting error considering the perceived complex and “bulky” set of questions. However, the fact that around half of the participants were community health extension workers (and one radiologist!) likely biased the results: they did not constitute the appropriate audience, which likely reduced their training self-efficacy and knowledge and skills retention [40]. Community health workers can play a critical role in preventing unsafe abortion and could have benefited from a curriculum that ensured better training utility and skills transfer. Such a curriculum could include, for instance, essential information for community awareness and mobilization, values clarification and attitude transformation, and even eligibility assessment for early medical abortion using a standardized checklist as demonstrated by the WHO [41]. The mismatch between participants and curriculum underscored the importance of offering the appropriate training to the right audience especially in resource-limited humanitarian settings.
Fourth, the recommendations summarized in Fig. 1 were valuable in improving the training module before its finalization. Although some of the recommendations may appear ordinary, especially for development settings, organizing and running capacity building events in humanitarian settings often face constraints in terms of security, time, material, and human resources. Immediate and longer-term transfer of learning may be influenced by a core set of factors, no matter the context [42]. Some of these factors emerged positively from the evaluation (acquisition of knowledge and skills, perceived relevance, attitudinal change, motivation, and confidence). Others, such as the in-clinic availability of supplies, materials, or job aids, should be improved to facilitate trainees’ autonomy to create opportunities to use their skills in health facilities.
Finally, the S-CORT approach relies on master trainers to travel to humanitarian settings. Outreach travel is a requirement but a significant limitation of the model, especially when movement restrictions are due to insecurity or infection control measures—the COVID-19 pandemic is an illustration of the latter [43]. In consequence, our model should adapt and integrate different training options that favor self-learning and remote teaching and mentoring through a blended approach. However, these mobile strategies rely on information technology and electronic platforms that may not be widely accessible to service providers working in humanitarian settings and would require further research. While uterine evacuation using medication may be suitable for mobile learning, manual vacuum aspiration requires preferably hands-on coaching. Mobile learning applications or modules should not suffer from a reductionist view subsumed under a mobile platform that neglects the complex relationship between adult learning principles and technology [44]. Therefore, the development of future mobile learning strategies drawing from the S-CORT should continue to be underpinned by adult learning theories, including collaboration, reflection, building on prior experiences, and focusing on improving practice instead of evaluation [45].