Mbonye Martin Kayitale, Burnett Sarah M, Naikoba Sarah, Ronald Allan, Colebunders Robert, Van Geertruyden Jean-Pierre, Weaver Marcia R
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda.
BMC Public Health. 2016 Aug 4;15:714. doi: 10.1186/s12889-016-3375-4.
Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) teams designed and implemented two health worker in-service training approaches: 1) an off-site classroom-based integrated management of infectious diseases (IMID) course with distance learning aspects, and 2) on-site support (OSS), an educational outreach intervention. We tested the effects of OSS on workload and 12 facility performance indicators for emergency triage assessment and treatment, HIV testing, and malaria and pneumonia case management among outpatients by two subgroups: 1) mid-level practitioners (MLP) who attended IMID training (IMID-MLP) and 2) health workers who did not (No-IMID).
Thirty-six health facilities participated in the IDCAP trial, with 18 randomly assigned to Arm A and 18 to Arm B. Two MLP in both arms received IMID. All providers at Arm A facilities received nine monthly OSS visits from April to December 2010 while Arm B did not. From November 2009 to December 2010, 777,667 outpatient visits occurred. We analyzed 669,580 (86.1 %) outpatient visits, where provider cadre was reported. Treatment was provided by 64 IMID-MLP and 1,515 No-IMID providers. The effect of OSS was measured by the difference in pre/post changes across arms after controlling for covariates (adjusted ratio of relative risks = a RRR).
The effect of OSS on patients-per-provider-per-day (workload) among IMID-MLP (aRRR = 1.21; p = 0.48) and No-IMID (aRRR = 0.90; p = 0.44) was not statistically significant. Among IMID-MLP, OSS was effective for three indicators: malaria cases receiving an appropriate antimalarial (aRRR = 1.26, 99 % CI = 1.02-1.56), patients with negative malaria test result prescribed an antimalarial (aRRR = 0.49, 99 % CI = 0.26-0.92), and patients with acid-fast bacilli smear negative result receiving empiric treatment for acute respiratory infection (aRRR = 2.04, 99 % CI = 1.06-3.94). Among No-IMID, OSS was effective for two indicators: emergency and priority patients admitted, detained or referred (aRRR = 2.12, 99 % CI = 1.05-4.28) and emergency patients receiving at least one appropriate treatment (aRRR = 1.98, 99 % CI = 1.21-3.24).
Effects of OSS on workload were not statistically significant. Significant OSS effects on facility performance across subgroups were heterogeneous. OSS supported MLP who diagnosed and treated patients to apply IMID knowledge. For other providers, OSS supported team work to manage emergency patients. This evidence on OSS effectiveness could inform interventions to improve health workers' capacity to deliver better quality infectious diseases care.
综合传染病能力建设评估（IDCAP）团队设计并实施了两种卫生工作者在职培训方法：1）一种基于校外课堂的具有远程学习环节的传染病综合管理（IMID）课程，以及2）现场支持（OSS），一种教育推广干预措施。我们通过两个亚组测试了OSS对工作量以及门诊患者急诊分诊评估与治疗、艾滋病毒检测、疟疾和肺炎病例管理的12项机构绩效指标的影响：1）参加IMID培训的中级从业者（MLP）（IMID-MLP），以及2）未参加培训的卫生工作者（未参加IMID者）。
36家卫生机构参与了IDCAP试验，18家被随机分配到A组，18家被分配到B组。两组中的两名MLP接受了IMID培训。A组机构的所有提供者在2010年4月至12月期间每月接受9次OSS访问，而B组则没有。在2009年11月至2010年12月期间，共发生了777,667次门诊就诊。我们分析了669,580次（86.1%）报告了提供者类别的门诊就诊情况。治疗由64名IMID-MLP和1,515名未参加IMID者提供。在控制协变量后，通过两组前后变化的差异来衡量OSS的效果（调整后的相对风险比=aRRR）。
OSS对IMID-MLP（aRRR = 1.21；p = 0.48）和未参加IMID者（aRRR = 0.90；p = 0.44）的每日每位提供者的患者数量（工作量）的影响无统计学意义。在IMID-MLP中，OSS对三个指标有效：接受适当抗疟治疗的疟疾病例（aRRR = 1.26，99%CI = 1.02 - 1.56）、疟疾检测结果为阴性但仍开具抗疟药的患者（aRRR = 0.49，99%CI = 0.26 - 0.92），以及抗酸杆菌涂片结果为阴性但接受急性呼吸道感染经验性治疗的患者（aRRR = 2.04，99%CI = 1.06 - 3.94）。在未参加IMID者中，OSS对两个指标有效：入院、留观或转诊的急诊和优先患者（aRRR = 2.12，99%CI = 1.05 - 4.28）以及接受至少一种适当治疗的急诊患者（aRRR = 1.98，99%CI = 1.21 - 3.24）。
OSS对工作量的影响无统计学意义。OSS对各亚组机构绩效的显著影响存在异质性。OSS支持诊断和治疗患者的MLP应用IMID知识。对于其他提供者，OSS支持团队协作管理急诊患者。关于OSS有效性的这一证据可为提高卫生工作者提供更高质量传染病护理能力的干预措施提供参考。
