Egger Joseph R, Stankevitz Kayla, Korom Robert, Angwenyi Philip, Sullivan Brittney, Wang Jun, Hatfield Sonia, Smith Emma, Popli Karishma, Gross Jessica
Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.
FHI 360, 359 Blackwell St Suite 200, Durham, NC 27701, USA.
Health Policy Plan. 2017 Jul 1;32(6):761-768. doi: 10.1093/heapol/czx004.
Mid-level care providers serve as the backbone of primary care in many parts of sub-Saharan Africa. Despite this, research suggests that the quality and consistency of this care is uneven. This study assessed the degree to which a set of four simple, low-cost interventions could improve adherence to a set of clinical quality measures (CQMs) associated with four common health conditions seen in a resource-constrained primary care setting.
A quasi-experimental, longitudinal study was carried out in three primary care clinics in Nairobi, Kenya from August 2014 to January, 2015. Mid-level clinical officers (COs) at each clinic participated in four interventions aimed at improving CQM adherence. A group of temporary COs acted as a control group. Clinical encounter data were abstracted from eligible medical charts and assessed for CQM adherence. Mixed-effects logistic regression models were then fitted to these data to determine whether adherence to CQMs improved over time, and if this adherence differed by provider type and other characteristics.
Adherence to CQMs increased from 41.4% to 77.1% for COs that took part in the intervention, and dropped slightly from 26.5% to 21.8% for temporary COs over the 6-month study period. This difference was statistically different between treatment groups and suggests that environmental interventions alone cannot change behaviour. Adherence also varied significantly by health condition, but did not vary by provider gender, age or clinic site.
This study demonstrates the potential for low-tech, low-cost interventions to improve the quality of care delivered by mid-level care providers in resource-constrained settings. Given the widespread utilization of mid-level care providers across sub-Saharan Africa, multicomponent interventions such as this one, that consist of simple educational modules and clinic-based feedback sessions, could lead to substantial improvements in the quality of primary care in these settings.
在撒哈拉以南非洲的许多地区，中级医疗服务提供者是初级医疗的支柱。尽管如此，研究表明这种医疗服务的质量和一致性参差不齐。本研究评估了一组四项简单、低成本的干预措施能够在多大程度上提高对一组与资源受限的初级医疗环境中常见的四种健康状况相关的临床质量指标（CQM）的依从性。
2014年8月至2015年1月，在肯尼亚内罗毕的三家初级医疗诊所开展了一项准实验性纵向研究。每个诊所的中级临床官员（CO）参与了旨在提高CQM依从性的四项干预措施。一组临时CO作为对照组。从符合条件的病历中提取临床诊疗数据，并评估CQM依从性。然后对这些数据拟合混合效应逻辑回归模型，以确定对CQM的依从性是否随时间提高，以及这种依从性是否因提供者类型和其他特征而异。
在6个月的研究期内，参与干预的CO对CQM的依从性从41.4%提高到77.1%，而临时CO的依从性则从26.5%略有下降至21.8%。治疗组之间的这种差异具有统计学意义，表明仅环境干预无法改变行为。依从性也因健康状况而有显著差异，但不因提供者性别、年龄或诊所地点而异。
本研究表明，低技术、低成本的干预措施有潜力提高资源受限环境中中级医疗服务提供者提供的医疗服务质量。鉴于中级医疗服务提供者在撒哈拉以南非洲广泛使用，像这样由简单教育模块和基于诊所的反馈会议组成的多组分干预措施，可能会大幅提高这些环境中初级医疗的质量。
