Evaluation of a five-day training programme on opioid substitution therapy in India

Abstract

Aims: In India, opioid substitution therapy (OST) has been scaled-up in the recent years for HIV prevention among injecting drug users. This study aimed to assess the change in knowledge and attitude of the OST staff who underwent a five-day training programme on OST. Methods: Using a “pre-test post-test” design, routine data collected from 267 staff who underwent the OST training was analysed. The staff composition was: doctors (n = 42, 15.7%), nurses (n = 49, 18.4%), counsellors (n = 45, 16.9%) and other programme staff (n = 131, 49.1%). A 20-item, pen and paper questionnaire was administered right before the beginning of and immediately after the completion of the training. The questions were categorised into one of the five domains to assess whether changes in scores are confined to certain domains. Overall scores and scores in different domains were compared using paired-sample t-tests. The score difference in different cadres was compared using univariate general linear model with post-hoc comparisons. Findings: The difference between the total mean pre-test scores (9.24) (out of maximum possible score of 20) and post-test score (13.8) was significant. Comparison between various domains showed significant differences across all cadres. Doctors recorded significantly higher scores compared to other cadres. Conclusion: It is feasible to train different cadres of service providers together on OST in five days. The training was able to improve the participants’ knowledge and their attitude towards injecting drug users.

• Opiate substitution treatment
• training
• physicians
• nurses
• counsellors

Introduction

The use of opiates through an injecting route is associated with high rates of Human Immunodeficiency Virus (HIV) and Hepatitis C (World Drug Report, 2014). Opioid substitution therapy (OST) is found to be highly effective for HIV prevention among injecting drug users (IDUs), and for treatment of opioid dependence (Connock et al., 2007; Dhawan, Jain, & Chopra, 2010; MacArthur et al., 2012; Mattick, Kimber, & Davoli, 2008; Mattick, Breen, Kimber, & Davoli, 2009). OST is considered as an essential component of the nine interventions for HIV prevention (WHO, UNODC & UNAIDS, 2012).

IDUs in India have high rates of HIV (7.2%). The National AIDS Control Organisation (NACO), which is the nodal Government agency to address HIV issues in India, supports OST as a strategy to prevent HIV among IDUs, and has scaled up OST centres in recent years. In the year 2013–14, 45 new OST centres were initiated, and more than 150 OST centres were functional through NACO support (NACO, 2014). These OST centres are located in hospitals with linkage to a nearby NGO that provides harm reduction services for IDUs. An OST centre is staffed with a doctor, nurse, counsellor and data manager who work full time in these centres to provide buprenorphine-based OST, counselling and healthcare referral services to the IDUs. The NGO refers IDUs to initiate OST and also follows up those who have dropped out from OST. A separate team from NGO comprised of a programme manager, a nurse, a counsellor and outreach workers carries out the referral and follow-up activity. A team of supervisors monitor the functioning of the OST centres (Rao, Agrawal, Kishore, & Ambekar, 2013; Singh & Ambekar, 2012).

A major issue in the scale-up has been the training to be delivered to the staff involved in the OST implementation, as most of the staff did not have prior experience in providing OST. The authors’ institution has been entrusted to develop training manual for ensuring uniform training on OST at the national level. A project supported by the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) provided the financial and human resource to conduct training on OST. The authors’ institution has been tasked to provide OST training to the staff from certain parts of India to provide them with the requisite knowledge and skills to provide OST to IDUs. The impact of these training programmes, however, has not been assessed. The aim of this study was to assess the change in the knowledge and attitude of the staff participating in these OST training programmes. Additionally, the study also sought to assess whether the changes vary between different cadres of staff, as well as between the various topics covered in the training.

Material and methods

The study followed a “pre-test post-test” design and used routine data collected as part of carrying out the OST training.

Details of OST training

The OST training is conducted in batches of 25–35 participants in which different cadres of OST staff are trained together in a residential programme of five days (about 30 h). Classroom training is delivered for four and a half days, and an exposure visit to an OST centre is organised for a half-day duration. The training programmes are conducted as per a training manual on OST especially developed for the purpose (Ray, Dhawan, & Ambekar, 2011). The training covers basic concepts of substance use and dependence, various strategies to manage drug abuse problem, principle and components of harm reduction, assessment and diagnosis of substance use disorder, pharmacology of buprenorphine, clinical aspects of OST, psychosocial interventions, and programme management issues including stock keeping, referral and networking, record keeping and reporting. A team of trainers (psychiatrists/social workers with experience in OST) conduct these training programmes. The training pedagogy involves presentations, role-plays and group discussions to improve the participants’ knowledge, attitude and skills related to OST.

A 20-item questionnaire is administered to each participant at the beginning and at the end of the training. The questions are in the form of multiple choice questions as well as true–false statements. The questions cover the following topics: knowledge about the effects of various drugs, criteria of dependence, drug-related harms and harm reduction, management of substance use disorder (drug abuse management), use of buprenorphine and its dose for use in OST, duration of OST, and roles of staff in OST implementation. The standard questionnaire has been developed as a part of the training manual to assess the change in knowledge and attitude of the participants with the training. The questionnaire also serves to gauge whether the participants have grasped the important skills of providing OST.

Data for the current study

We used data collected from nine OST training programmes conducted from August 2013 to August 2014 for this study. A total of 267 OST staffs participated in these nine training programmes. Participant responses in the pre- and post-test questionnaire were analysed. The questions were further classified into five domains of drug abuse management, harm reduction, HIV/AIDS, OST and attitude towards substance use disorder. Five experts (three of them being the authors AA, AAg and RR) independently categorised each question in one or more of these domains. The experts could also suggest another domain if it was felt that a particular question does not fit in the existing domains. A particular question was assigned to a domain, if the domain was suggested by more than one expert. Thus, a given question could be assigned to more than one domain.

Statistical analysis

Participants’ overall scores and domain scores were compared using paired sample t-tests. The general linear model (GLM) was used to perform univariate analysis which provides regression analyses and analysis of variance for one dependent variable by factors or variables. In this study, the difference in the total pre- and post-test scores as well as the difference in the domain scores was calculated; this difference was considered as the dependent variable. The category of staff was considered as the factor in the model. Levene’s test was used to test the assumption for the equality of error variance. As there was significant difference found in two of the dependent variables (total score and scores on drug abuse management), pair-wise multiple comparison in the mean scores was then performed to assess whether there were significant differences between two cadre-groups. Tukey’s post-hoc test was used for deriving the adjusted p value for multiple comparisons. The analysis was performed by licensed SPSS 21.0 version software (IBM SPSS Statistics for Windows, Version 21.0, Armonk, NY).

Results

The mean age of the participants was 32.5 (SD: 9.3, range: 17–75) years. The cadre-wise distribution was: Doctors – 42 (15.7%), Nurses – 49 (18.4%), Counsellors – 45 (16.9%), other programme staff – 131 (49.1%). The other programme staff comprised data managers of the OST centres (n = 25), programme managers (n = 25) and outreach workers (n = 66) of the NGOs, and monitoring officers (n = 15). Males comprised 66% (n = 176) of the total participants. About 58% doctors were medical graduates, while the rest were specialists. Only four doctors were psychiatrists. Majority (90%, n = 44) of the nurses had completed auxiliary/general nursing and midwifery, while the rest were graduates or masters in nursing. About 45% (n = 24) of the counsellors had completed masters in sociology, four participants were masters in psychology, while 35% (n = 16) were graduates in humanities/sociology. Majority (88%, n = 237) had some work experiences before joining the OST centre. About 63% (n = 168) of the participants had no experience in OST before attending the training, while the rest had spent a median of three months (IQR: 2, 9.75 months) working in the OST centre before they attended the training.

The maximum possible score that could be obtained in the pre-test or post-test was 20. The total mean pre-test and post-test score obtained by the participants was 9.24 (SD: 2.6) and 13.8 (SD: 2.8), respectively; the difference between the two scores was statistically significant (p < 0.01). There was also significant difference between the pre- and post-test scores in all the five assessment domains. Table 1 shows the total score as well as scores on different domains.

Table 1. Comparison of pre-test and post-test scores obtained by the participants.

		Mean (SD)		CI for difference (Post–Pre)
Variable^a	Maximum Possible score	Pre-test	Post-test	Lower bound	Upper bound	t-test	P value^b
Total score	20	9.24 (2.57)	13.8 (2.8)	4.17	4.94	23.07	<0.001
Drug abuse management	16	6.66 (2.2)	10.55 (2.43)	3.55	4.24	22.06	<0.001
Understanding opioid substitution therapy	8	3.57 (1.55)	5.33 (1.49)	1.53	2.00	14.86	<0.001
Understanding harm reduction	8	4.24 (1.52)	5.78 (1.49)	1.30	1.77	13.10	<0.001
Understanding HIV/AIDS	3	1.92 (0.82)	2.39 (0.76)	0.35	0.59	7.56	<0.001
Attitude towards substance use disorder	8	4.39 (1.5)	6.15 (1.42)	1.53	1.99	15.08	<0.001

^a The sum of individual domain scores can be more than 20, as an item could figure in more than one domain.

^b Statistically significant at p < 0.05.

SD: Standard Deviation; CI: Confidence Interval.

Significant differences between the cadres in overall scores, as well as in the domains of “Drug abuse management” and “Understanding harm reduction” were also observed. Levene’s test showed homogeneity of variances in all domains. On Tukey’s post-hoc comparisons, difference in overall scores (Doctors > Counsellors (p = 0.008), Doctors > others (p = 0.011)) and scores on “Drug abuse management” (Doctors > Counsellors (p = 0.007), Doctors > others (p = 0.015)) were found to be significantly higher among the doctors compared to the counsellors or other staff. The differences were not significant compared to the nurses’ scores. Table 2 shows the mean score difference in total scores as well as scores in the five domains across the four staff categories, as well as the p value obtained by Levene’s test. The adjustment in p value for multiple comparisons between staff categories is provided in the last column of the table.

Table 2. Cadre-wise comparison of differences in pre-test and post-test scores obtained by the participants.

	Doctors	Nurses	Counsellors	Others
Cadre	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Levene's (p)	F	p^a	Post-hoc
Variable
Total Score	6 (2.6)	4.8 (2.8)	3.8 (3.3)	4.2 (3.4)	0.326	4.246	0.006^a	D > C (0.008)^a D > O (0.011)^a
Drug abuse management	5.2 (2.3)	4 (2.7)	3.2 (3)	3.7 (3)	0.359	4.124	0.007^a	D > C (0.007)^a D > O (0.015)^a
Understanding Opioid substitution  therapy	2.5 (1.8)	1.8 (1.8)	1.5 (2)	1.6 (2)	0.635	2.364	0.072
Understanding Harm reduction	2.1 (1.8)	1.9 (1.9)	1.2 (2)	1.3 (1.9)	0.736	2.665	0.048
Understanding HIV/AIDS	0.5 (1.1)	0.5 (1)	0.5 (1.1)	0.4 (1)	0.783	0.424	0.736
Attitude towards substance use disorder	2.2 (1.6)	1.8 (2.2)	1.8 (2)	1.6 (1.9)	0.291	1.216	0.304

^a Statistically significant at p < 0.05.

D: Doctors; C: Counsellors; SD: Standard Deviation; O: Other programme staff.

Discussion

Even though OST has been proven to be an effective HIV prevention intervention, less than 5% IDUs receive OST globally and in South Asia (Mathers et al., 2009; Rao et al., 2013). Various barriers to use OST exist among service providers and service recipients. These include unfavourable drug policies and laws, cost and availability of OST medicines, service providers’ attitude and inadequate qualification and training on OST (Besson et al., 2014; Longman, Temple-Smith, Gilchrist, & Lintzeris, 2012; Marshall et al., 2012; Puskar et al., 2013; Scott et al., 2012; Shakeshaft, Nassirimanesh, Day, & Dolan, 2005). Unfortunately, the time allotted to the training on diagnosis and management of substance use disorder in undergraduate medical or other courses is very limited (Polydorou, Gunderson, & Levin, 2008; Rasyidi, Wilkins, & Danovitch, 2012). Hence, training programmes on specific treatment strategies such as OST are needed to equip service providers with requisite knowledge and skills to treat opioid dependence.

Duration becomes an important factor to consider while designing training programmes (Isaacson, Fleming, Kraus, Kahn, & Mundt, 2000). There is no consensus on the ideal duration of such specialised training. Studies report variable duration from two and a half days to four days for training to be effective (Alford et al., 2009; Gunderson, Levin, & Owen, 2008). This study showed that a period of five days was sufficient to improve the knowledge and attitude of participants immediately after training. Hughes et al., 2008, demonstrated that the effectiveness is sustained until 18 months if the five-day training is combined with monthly supervision.

All the cadres in this study showed improvement in post-test scores, demonstrating that it is possible to train different cadres together even on the specialised topic of OST. Studies assessing training impact on other health-related aspects such as HIV or specific psychotherapies show similar results (Deren, Kang, Mino, & Guarino, 2012; Diesel, Nsagha, Sab, Taliaferro, & Rosenburg, 2011; Jaffray et al., 2014; Nyamathi et al., 2008; Williams et al., 2014; Wolfe et al., 2013). Gohns, Buetow, and McCormick (2002), reported that general practitioners, pharmacists and nurses trained together reported satisfaction and benefits from the training. This study also shows that doctors may benefit more as compared to other cadres, as seen in the score differences. There may be various reasons postulated for this difference. The training method followed may be more suitable for knowledge acquisition by doctors compared to other staff. Doctors may also be more tuned to continuous updating of knowledge and skills due to constant exposure to other learning programmes such as continued medical education. The significant improvement in knowledge of doctors and nurses is important, as the medical staff members are the most important part of providing OST. Follow-up training programmes and other mechanisms such as onsite supervision may be required for other staff members such as counsellors to further improve their knowledge and skills.

Service providers are often reluctant to work with drug users due to negative attitudes towards drug users (Longman et al., 2012). Hence, training must improve knowledge as well as provide opportunity to cultivate positive attitudes towards the drug using population (Renner, Quinones, & Wilson, 2005). This study demonstrated improvement in the participants’ knowledge as well as attitude towards IDUs.

A major limitation of the study is that the changes in knowledge and attitude were assessed immediately at the end of the training. Future studies are required to assess whether the improvement observed would be sustained over a longer period. The questionnaire used was not validated. Also, the same questions were used to assess the changes. The participants would have tried to memorise the answers to these questions during the training course, which might lead to artificial increases in post-test scores, rather than because of training. Finally, test–retest design was used, which is an inferior study design, as compared to other study designs such as parallel-arm design. However, the data analysed was collected during routine programme, and hence the results reflect the real world situation.

Conclusion

The study shows that it is feasible to conduct training on OST for different cadre of service providers together over a period of five days. The training was able to change the participants’ knowledge on substance use disorder as well as their attitude towards IDUs.

Declaration of interest

Three authors (RR, AA and AAg) received honoraria to conduct these training programmes.

Funding for the present research: none.