Abstract

BackgroundIntegrated 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).MethodsThirty-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).ResultsThe 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).ConclusionEffects 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.Electronic supplementary materialThe online version of this article 10.1186/s12889-016-3375-4) contains supplementary material, which is available to authorized users.

Highlights

  • 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

  • Participant flow The flow of the participating health facilities, and IMID training and OSS participants is presented in Fig. 2 [33]

  • This was expected since mid-level practitioners (MLP) involved in daily management of patients in the outpatient clinics and spent over 80 % of their time at the health facility seeing patients were prioritized during the selection process [20]. These results for the MLP with IMID training are consistent with those of the Institute for Health Metrics and Evaluation’s report that showed health providers saw an average of three to five patients per day [43]. These results indicate that health workers in Uganda treat very few patients per day, but this finding contrasts with other reports in which complaints of heavy workload have been cited among health workers in Uganda [44] and other sub-Saharan Africa countries [45, 46]

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Summary

Introduction

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. The shortage of physicians in sub Saharan Africa is at critical levels, with only 2 physicians per 10,000 population compared to 28 in high-income regions [3] This shortage of physicians has led to many physician roles, such as initiation of antiretroviral therapy shifting to mid-level practitioners (MLP) with fewer years of medical training [4], formally [5,6,7] and informally [8, 9]. As reported in one Ugandan study, many of these MLP have not been trained to take on these tasks [10] They require capacity building to meet the demands of changing health policies and guidelines [11]. Several systematic reviews show that classroom-based training may not equip the attendants with sufficient skills to ensure adherence to clinical guidelines [17,18,19]

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