Influence of the Simulation in the Training of the 7 th Grade Medical Students in the Insertion of the Interval Intra-Uterine Device

Introduction: A simulation laboratory has been set up in the Department of Obstetrics and Gynaecology at Yalgado Ouedraogo Teaching Hospital. The objective of this study was to evaluate the role of the simulation in training of 7 th grade students on interval IUD insertion. Material and Method: This was an evaluation study of skills before and after training that included 38 students of 7 th grade medicine. Pre-training knowledges and skills were compared to those based on training using the paired Student test with a 5% sig-nificance level. Perceptions and suggestions for improvement of training made by students were collected. Results: The sex ratio of the study partici-pants was 1.1. Their average age was 26.8 ± 0.9 years. The training increased the average knowledges score from 48.2% to 93.0% (p < 0.001). The average skills score increased from 34.4% to 92.8% (p < 0.001). The 7 th grade medicine students had a good perception of this training. Conclusion: The training of 7 th grade medicine students in IUD insertion using simulation had a positive impact on their knowledges and skills and was well appreciated.


Introduction
In Burkina Faso, maternal and neonatal morbidity and mortality are high [1].
One of the pillars retained by the country for the reduction of this health problem is family planning (FP). Among FP methods, the intrauterine device (IUD) offers the best cost-benefit ratio [2] [3]. Burkina Faso has opted to promote this method but its insertion requires a technical nature requiring quality training.
Interval insertion of IUD is done after the first 42 days after delivery.
In the curriculum for general practitioners, a theoretical lesson followed by a practice in family planning is given to students in grade 5. Then the students in grade 7 benefit from a clinical internship in obstetrics and gynaecology. Since 13 July 2018, the Department of Obstetrics and Gynaecology (DOG) at the Yalgado Ouedraogo University Hospital Center (UHC-YO) has been equipped with a skills' laboratory. This laboratory provides an opportunity for students to acquire skills on anatomical models before practicing on real patients. The objective of this study was to evaluate the influence of simulation in training 7 th grade students on the interval IUD insertion. The 7 th grade students are students in their final year of general medical studies.

Methods
It was an analytical cross-sectional study that evaluated the impact of training using an anatomical model. It took place from 02 to 28 February 2019 in the skills' laboratory in the DOG of UHC-YO. This skills' laboratory has 5 stations to learn about fifteen clinical skills. The study involved all the 38 grade 7 students assigned to the DOG for their practical training. The variables collected were the socio-demographic characteristics of the students, the knowledge variables namely the ability to check the contraindications of IUD insertion: absence of pregnancy or uterine anomaly, cervical dysplasia, acute pelvic inflammatory disease, untreated acute cervicitis or vaginitis before insertion of the interval IUD. The participants' knowledges of the equipment for interval IUD insertion, of the order of the gynaecological examination preceding the interval IUD insertion, the interval IUD insertion procedure, interval IUD efficacy were also collected. The variables used for the assessment of skills were the mastery of the steps of interval IUD insertion, the respect of the order of execution of the steps of the interval IUD insertion. The variables for assessing the perception of interest of the skills' laboratory were the answers to the following statements: "the skills' laboratory is a good learning tool" and "the skills lab helped me in acquiring proficiency for interval IUD insertion". The students had to use the Likert scale [4] as follows to give their views in relation to each of statements: not at all agree = 1; not agree = 2; neither disagree nor agree = 3; agree = 4; totally agree = 5.
After explaining to the students, the course of interval IUD training, a standardised cognitive pre-test was administered to them. Then each student was observed to insert an IUD on an anatomical model. Using the structured observational fiche, the teacher gave a score for the practice. The addition of the cognitive score and the observational score for interval IUD insertion allowed an overall score for each student. Then, the students were distributed into 4 groups of 12 to 13. Each group received a theoretical course recalling the mechanism of action of the copper IUD, the stages of its insertion and specific counseling to Open Journal of Obstetrics and Gynecology this contraception method. Using a standardization fiche, teachers demonstrated the interval IUD insertion. Then by subgroup of 6, the students practiced for 4 hours under a teacher's guide, always using the standardization fiche. After all students in all groups benefited the training, a theoretical and practical assessment using the same questionnaire and the same observational fiche was conducted.
Data collected from the study were recorded in the Microsoft Office Excel 2010 and subsequently analyzed using Epi Info version 7 software package. Performance scores obtained before and after training were compared using the paired Student's t-test. A difference was considered significant if p < 0.05. At the operational level, we defined: -good performance level if overall score ≥ 85%.
-insufficient level of performance if overall score ≤ 50.
The data collection was anonymous. The confidentiality of the data has been respected. Because the study is part of a normal training process for students and this without human manipulation, the agreement of the ethics committee is not required in Burkina Faso.

Study Population Socio-Demographic Characteristics
The students' average age was 26.8 ± 0.9 years. The extreme ages were 25 and 29 years old. Among the 38 students, 20 (52.6%) were male. The sex ratio was therefore 1.1. In terms of nationality, there were 31 (81.6%) Burkinabe, 4 Chadians, 2 Beninese, 1 Cameroonian. Thirty students had completed their secondary education in Benin, four in Ivory Coast, two in Chad, and two in Cameroon. Table 1 shows the sociodemographic characteristics of the students.

Results of before Formation Assessment
Thirty-eight (38) 7 th grade students participated in this initial assessment. The average score was 48.2% for theoretical knowledge with extremes of 22.2% and

Results of after Formation Assessment
All the 38 grade 7 students took part in the training assessment. The mean for theoretical knowledge score was 93.0% ± 6.4%. The extreme scores were 77.8% and 100.0%. All 38 grade 7 students took part of after training assessment on infernal UID insertion using anatomical model. The average score was 92.8% with extreme scores of 63.6% and 100%. The average global score was 92.9% with extremes of 85% and 100%. Figure 1 shows the results of the answer to theoretical questions and practice per student. Figure 2 shows the boxplot of global score before and after training.    Figure 3 compares the average scores by 7 th grade students in the assessment of theoretical knowledges before and after training. The theoretical knowledge score was higher after training that before it. The difference was statistically significant. Figure 4 compares the average scores obtained by 7 th grade students in the assessment of skills on anatomical model before and after training. The skills' score was higher after training that before it. The difference was statistically significant.   Table 2 gives the responses of 7 th grade students at the assertion "skills laboratory is a good learning tool". Ninety-seven-point four percent (97.4%) of 7 th grade students either agreed or strongly agreed with the statement. Table 3 gives the responses of 7 th grade students to the assertion "the skills' laboratory helped me in acquiring skills for the interval IUD insertion". All 7 th grade students were either agreed or strongly agreed with the statement.

Strengths and Weaknesses of the Study
The purpose of this study was to evaluate the impact of the training on the improvement of trainees' knowledge and skills on the insertion of the interval IUD.
One of the weaknesses of the study is that it did not take into account all 7 th grade students of the promotion. In fact, not all trainees are doing the Obstetrics Gynaecology stage at the same time. They are divided into several groups and each group does their internship for 3 months. Another weakness is the simulation tool used which does not allow a perfect reproduction of the reality of interval IUD insertion in a real woman. Despite these weaks, the study has a strength in that it has an analytical study which compared knowledge and skills of 7 th grade students before and after training. In addition, the assessment was done by the same teachers thus reducing the risk of variability of appreciation.

Impact of Training Using Simulation for Skills' Acquisition
Our study showed how a short theoretical training followed by the use of simulation on anatomical model can help the acquisition of knowledge and clinical skills. Martineau et al. [5] have shown that learners' feedback facilitates the learning of complex gestures. In our study, this feedback was made by peers (the

Perceptions of 7 th Grade Students about the Usefulness of the Simulation
The students of grade 7 had a good appreciation of the training by simulation using the anatomical model in the clinical skills laboratory. All recognized that this laboratory has been of great help to them in acquiring clinical skills. Other authors like Lemay et al., Nash and Harvey, Falloon, and Juhary also found that learners appreciate the use of simulators in their training [7] [16] [17] [18]. This positive perception by the learners is a factor of good attendance at teaching sessions. In our study, all 7 th grade students who started training completed this.

Conclusion
Our study population included 7 th grade students. The training of these students on the insertion of the IUD using an anatomical model allowed a clear improvement of their knowledge and skills. This training was well appreciated by these students. For these reasons, the simulation on anatomical models can be promoted in the medical schools. Simple anatomical models can be used in low-income countries.