Qualitative assessment of providers’ experiences with a segmentation counseling tool for family planning in Niger

A total of 16 health care providers participated in the study, with a 100% participation rate. The 16 providers interviewed had all been trained in segmentation and had been using the segmentation tool for a mean of 16 months (range 1–60 months). Although the plan was to include eight providers from each arm, in the end, interviews were collected from seven providers from Arm 1 of the study and nine providers from Arm 2. The providers represented four distinct roles at the CSIs: Chief of the CSI (3 providers), Deputy Chief of the CSI (3 providers), Nurse (5 providers), and Midwife (5 providers). The mean age of the providers was 38 years and they were predominately female (81%). Half of the 16 interviews were with providers from Boboye health district, with the rest of the interviews represented by Dosso (3 interviews), Doutchi (3 interviews) and Loga (2 interviews) health districts. The mean number of years providing family planning services was eight years, with a range from 1 to 28 years. There were two types of trainings offered in segmentation, either a full five-day training or an on-site briefing at the CSI by either another CSI staff person who had attended the full training or by someone associated with Pathfinder International. In total seven of those interviewed had received the full five-day training in segmentation and six had received a briefing. Three providers did not specify the type of training received. See Additional file 1: Table S1.

All four coders involved in coding the segmentation parent codes had an average Cohen’s kappa score of 0.79 and a range of 0.72–0.89, when each was compared to a master coder. The two child code coders had an average Cohen’s kappa score of 0.69 for coding of the segmentation codes when compared to a master coder (see Additional file 2: Table S2). All these scores show substantial agreement (between 0.61 and 0.80 kappa score) and two show almost perfect agreement (between 0.81 and 1.00 kappa score) [23].

Training

Since all 16 interviewees had received either the five-day or brief training on the segmentation tool, they were asked about what the content of the training had been to gauge their comprehension of content and experiences across the two training formats. Responses from providers about their training was important because training was a prerequisite for providers to use the segmentation tool and provider responses reflect and verify that they had received the training content needed to make them comfortable using the segmentation tool.

A total of 15 respondents provided information on the content of their training. All respondents reported that the segmentation training, in whatever format, mainly focused on how to implement the segmentation tool and the accompanying counseling cards.

“She just explained to us a template that she used. How we ask a woman questions, and how we take notes from the answers… at the end you check the number, you circle the greatest number, then you check the total. Based on this, you report what is written on the sheet. For example, if it is in TA [Traditional Autonomist], you report TA on the form. Checking the card, you will see Traditional Autonomist. This is what she showed us”.

-Deputy Chief who received a briefing on segmentation

A little over half of the respondents reported that the training included content on best practices for counseling using the segmentation approach, though many respondents did not mention counseling as a specific content area.

Other content reported was a brief overview of family planning technologies and reproductive health and time spent translating the tool from French into local languages. Generally, the full trainings were the most well received.

“We were trained in Dosso, we were trained on the segmentation strategy, on how to assess women’s knowledge about FP [Family Planning], how to classify a woman regarding her knowledge. During the training, we had no problems, the trainers were really impeccable because they trained us very well, we learned a lot from them.”

-Chief who attended full segmentation training

A total of ten respondents provided information on the type of additional content they would desire in a training. A main theme that emerged among respondents was a desire to have more in depth training on segmentation. This was reported especially from those health care providers who had been briefed on segmentation by the Pathfinder International team instead of attending a full five-day training.

“What I want is that my capacities regarding the segmentation strategy be strengthened. I need training on that.”

-Midwife who received a briefing on segmentation

Supervision

Eleven of the 16 respondents confirmed that they had received a supervision visit after the training. Questions about supervision were included because supervision visits were meant to support providers in the use of the segmentation counseling tools and helped refresh previously-trained providers on the use of the segmentation tools and gave an opportunity for a briefing of untrained providers on how to use the tools. Supervision visits happened through both planned and unplanned visits to the facility. Respondents reported that the supervision visits included members of the Pathfinder International team, health district agents and agents from the regional public health directorate (Direction Régionale de la Santé Publique). In addition to a review of segmentation procedures, most of the providers reported that the supervision team reviewed the CSI’s data in terms of the proportion of clients segmented.

“Yes, there was a visit during which, when the team came, they took the cards to count the number of women segmented and those who are not. Then they did the percentage calculation. This is what they did in addition to checking the product inventory. Then they asked us questions about what we need to be clarified.”

- Deputy Chief who received a briefing on segmentation

Eight providers, of the 11 who had stated that they had received a supervision visit, provided reflections on the supervision visits. Five of these eight providers reflected that the supervision visit helped them with segmentation.

“This benefited me because there are parts where I did not understand anything about the questionnaire during the training, because the trainers are Hausa. But when the supervision came, they explained it to me and I understood.”

-Midwife who received a briefing on segmentation

Process of implementation

During the interviews, the 16 providers were asked about the process used in their CSI to segment clients. Providers reported that first, when a client arrives at the clinic, they welcome and register all clients as they normally would, asking the reason for their visit. When the client begins a family planning consultation, the providers check a woman’s family planning file to see if the segmentation tool has been filled out and filed previously and, if not, they proceed to segmentation. Half of the providers responded that they segment only new clients to the CSI but many said they also segment returning clients if they have not yet been segmented. The rest did not specify.

“Anyone that comes has a card. For example, this one is an old one, she has a card and has never been segmented. We segment her and we mention it on the card. If it's a first visit case, we also segment her and mention it on her card.”

-Midwife who received a briefing on segmentation

All providers said that they use the segmentation tool with every kind of family planning client—young, married, unmarried, multiparous and nulliparous.

“Interviewer: For all clients that come, do you need to do the segmentation for them or not?”

“Provider: Me, for all women that come, I do the segmentation.”

“Interviewer: And the counseling cards, do you use them with all women or not?”

“Provider: I use it with all women.”

-Chief who attended full segmentation training

The steps of the segmentation process during a clinic visit were explained fully by a few providers, especially for new family planning clients.

“After that I’m going to record the woman, give her a number like she is really new. I’m going to give her a FP card, this woman should be segmented, we must segment her, ask her questions. Now after having segmented her, we will see in which group she falls and we will check and see the kind of advice that the girl needs to give her according to the different segments, if she is a traditional autonomous, a conservative passive or something like that ...”

-Deputy Chief who received a briefing on segmentation

Impact of segmentation

The 16 providers interviewed were asked about the way in which segmentation changed the family planning services they offer. All the providers except for one responded that the use of the segmentation tool increased the amount of time needed for the delivery of family planning services. Respondents said this extra time allowed them to provide more information about family planning to their clients and led to more individualized counseling.

“Interviewer: Are the questions you are asking, are they taking longer now than when there was no segmentation?”

“Provider: We need much more time now. Because, it was just the method before. But now, in addition to the method, there is segmentation, so it takes more time.”

-Midwife who received a briefing on segmentation

“It allows you to interact more with the client and spend more time. The client becomes comfortable and trust develops between you.”

-Nurse who did not specify the type of training received

Nevertheless, the extra time needed to implement the tool was sometimes a challenge for providers. For example, a few providers said they could not implement the tool on market days due to the number of women seeking family planning on those days and the amount of time it would take to segment them all. However, some providers said that the segmentation tool became easier to use with time and did not take as much time as at the beginning.

“There is only one difficulty when you are at the beginning of its use, even being too slow with the questions asked to women at the beginning, they think that they are wasting their time, is already a difficulty. But over time, if the health provider gets used to it, there will come a time when he doesn’t have to look at the grid to be able to ask questions, and he can finish it in two minutes.”

-Deputy Chief who received a briefing on segmentation

The providers explained that the clients who had been segmented had a better understanding of family planning, of the utility and importance of family planning, and had more knowledge of different family planning methods and how they worked.

“There is really a difference, because now you take your time, before doing FP, you make it very clear to the woman by explaining to her in her language, she answers you and you take note and after that you take the advice card, you explain to the woman how things work… now with segmentation you are obliged to go step by step so that the woman understands, and with the advice card you explain again to the woman. There are women who say, at the end of their counseling, that they are able to explain to other women who don’t understand FP.”

-Deputy Chief who received a briefing on segmentation

“And usually, women receive much more information, even regarding the method they are using. They are using these methods, but before, it’s the system that doesn’t allow us to give all the information about the methods.”

-Chief who attended full segmentation training

Half of the providers stated that women learned about the segmentation approach from other women in their communities and their interest in family planning grew from there. A few providers noted that segmentation reduced beliefs in rumors about family planning. One provider gave an example of a client who asked why she was not segmented during her visit (the provider said she was too busy to segment that day) so the client came back another day to be segmented and learn about the methods available to her.

“Interviewer: Has it [segmentation strategy] improved or disadvantaged the FP service you offer?”

“Provider: It has improved the service.”

“Interviewer: how?”

“Provider: Before, clients did not come abundantly for FP; but now, due to the conversations, we explain to them and they understand the usefulness of family planning. There are many to come.”

-Nurse who did not specify the type of training received

“Provider: First, with the old counseling method, where there was no segmentation, it was not possible to explain much to the woman the importance of FP, whereas with segmentation, with the questions that we ask the woman, we understand to which segment she belongs, and this helps to better sensitize her so that she accepts FP better, but also that she makes others accept as well. We transform her into a kind of relay so that she sensitizes other women to use FP. So, when a woman comes here, a hesitant woman, or a woman who does not have too much confidence, after the segmentation, we are sure that she is 100% confident in using FP, but also, she can ensure that other women also trust FP.”

-Chief who attended full segmentation training

Difficulties with segmentation

Fourteen of the 16 respondents who had experience with using the segmentation tool provided insight into the most common difficulties they faced when using the tool. The respondents indicated that there were three main themes that emerged regarding difficulties with the tools: lack of comprehension of the questions by the clients, difficulties in translating the questions into the local languages and the need for further training in segmentation (see Training above).

Providers noted that clients often had a lack of comprehension of the segmentation questions, which meant that the provider had to re-explain the question several times in the local language before the client fully understood. In many cases the provider was translating directly from French into the local language.

“Interviewer: What are the difficulties you encounter in using the segmentation tool?”

“Provider: Sometimes it’s the questions, because at least and fortunately for others there is the translation into Zarma, but when it’s in French how to translate on the spot by asking the questions, sometimes it’s really difficult. In any case, that’s the difficulty, translating the questionnaire into Zarma, the client may not understand what you really mean, you have to explain the question again, that's my great difficulty.”

-Midwife who received a briefing on segmentation

The lack of comprehension of questions in the tool was closely linked with difficulties associated with translating tool questions from French into the local language. This was another main difficulty that emerged from the interviews. However, it did seem that this was a difficulty that improved over time.

“Well, when I did the training on the segmentation tool, everything is in French, we translated that afterwards into Hausa and I mastered it little by little, with the learning and the proof is that you see that sometimes I try to explain some to you without the card.”

-Nurse who attended full segmentation training

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