Lewin Simon, Dick Judy, Zwarenstein Merrick, Lombard Carl J
Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, England.
Bull World Health Organ. 2005 Apr;83(4):250-9. Epub 2005 Apr 25.
To assess whether adding a training intervention for clinic staff to the usual DOTS strategy (the internationally recommended control strategy for tuberculosis (TB)) would affect the outcomes of TB treatment in primary care clinics with treatment success rates below 70%.
A cluster randomized controlled trial was conducted from July 1996 to July 2000 in nurse-managed ambulatory primary care clinics in Cape Town, South Africa. Clinics with successful TB treatment completion rates of less than 70% and annual adult pulmonary TB loads of more than 40 patients per year were randomly assigned to either the intervention (n = 12) or control (n = 12) groups. All clinics completed follow-up. Treatment outcomes were measured in cohorts of adult, pulmonary TB patients before the intervention (n = 1200) and 9 months following the training (n = 1177). The intervention comprised an 18-hour experiential, participatory in-service training programme for clinic staff delivered by nurse facilitators and focusing on patient centredness, critical reflection on practice, and quality improvement. The main outcome measure was successful treatment, defined as patients who were cured and those who had completed tuberculosis treatment.
The estimated effect of the intervention was an increase in successful treatment rates of 4.8% (95% confidence interval (CI): -5.5% to 15.2%) and in bacteriological cure rates of 10.4% (CI: -1.2% to 22%). A treatment effect of 10% was envisaged, based on the views of policy-makers on the minimum effect size for large-scale implementation.
This is the first evidence from a randomized controlled trial on the effects of experiential, participatory training on TB outcomes in primary care facilities in a developing country. Such training did not appear to improve TB outcomes. However, the results were inconclusive and further studies are required.
评估在常规直接观察短程化疗策略（国际推荐的结核病控制策略）基础上，增加针对诊所工作人员的培训干预措施，是否会对治疗成功率低于70%的基层医疗诊所的结核病治疗结果产生影响。
1996年7月至2000年7月，在南非开普敦由护士管理的门诊基层医疗诊所开展了一项整群随机对照试验。结核病治疗完成成功率低于70%且每年成人肺结核患者负担超过40例的诊所被随机分为干预组（n = 12）或对照组（n = 12）。所有诊所均完成随访。在干预前（n = 1200）和培训后9个月（n = 1177）对成年肺结核患者队列测量治疗结果。干预措施包括由护士辅导员为诊所工作人员提供的为期18小时的体验式、参与式在职培训项目，重点是患者中心性、对实践的批判性反思和质量改进。主要结局指标为成功治疗，定义为治愈患者和完成结核病治疗的患者。
干预措施的估计效果为成功治疗率提高4.8%（95%置信区间（CI）：-5.5%至15.2%），细菌学治愈率提高10.4%（CI：-1.2%至22%）。根据政策制定者对大规模实施的最小效应量的看法，设想的治疗效果为10%。
这是来自一项随机对照试验的首个证据，表明在发展中国家的基层医疗设施中，体验式、参与式培训对结核病治疗结果的影响。此类培训似乎并未改善结核病治疗结果。然而，结果尚无定论，需要进一步研究。
