Abstract
BackgroundThe effects of two interventions, Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS), were tested on 23 facility performance indicators for emergency triage assessment and treatment (ETAT), malaria, pneumonia, tuberculosis, and HIV.MethodsThe trial was implemented in 36 primary care facilities in Uganda. From April 2010, two mid-level practitioners per facility participated in IMID training. Eighteen of 36 facilities were randomly assigned to Arm A, and received OSS in 2010 (nine monthly two-day sessions); 18 facilities assigned to Arm B did not receive OSS in 2010. Data were collected from Nov 2009 to Dec 2010 using a revised Ministry of Health outpatient medical form and nine registers. We analyzed the effect of IMID training alone by measuring changes before and during IMID training in Arm B, the combined effect of IMID training and OSS by measuring changes in Arm A, and the incremental effect of OSS by comparing changes across Arms A and B.ResultsIMID training was associated with statistically significant improvement in three indicators: outpatients triaged (adjusted relative risks (aRR) = 1.29, 99%CI = 1.01,1.64), emergency and priority patients admitted, detained, or referred (aRR = 1.59, 99%CI = 1.04,2.44), and pneumonia suspects assessed (aRR = 2.31, 99%CI = 1.50,3.55). IMID training and OSS combined was associated with improvements in six indicators: three ETAT indicators (outpatients triaged (aRR = 2.03, 99%CI = 1.13,3.64), emergency and priority patients admitted, detained or referred (aRR = 3.03, 99%CI = 1.40,6.56), and emergency patients receiving at least one appropriate treatment (aRR = 1.77, 99%CI = 1.10,2.84)); two malaria indicators (malaria cases receiving appropriate antimalarial (aRR = 1.50, 99%CI = 1.04,2.17), and patients with negative malaria test results prescribed antimalarial (aRR = 0.67, 99%CI = 0.46,0.97)); and enrollment in HIV care (aRR = 1.58, 99%CI = 1.32,1.89). OSS was associated with incremental improvement in emergency patients receiving at least one appropriate treatment (adjusted ratio of RR = 1.84,99%CI = 1.09,3.12).ConclusionThe trial showed that the OSS intervention significantly improved performance in one of 23 facility indicators.
Highlights
The effects of two interventions, Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS), were tested on 23 facility performance indicators for emergency triage assessment and treatment (ETAT), malaria, pneumonia, tuberculosis, and human immunodeficiency virus (HIV)
The percentage analyzed for the indicators that were based on the facility-month data from the revised Medical Form 5 (MF5) were generally above 95%, dropping below 95% for indicators that relied on drug stock data or were missing data on covariates for subgroups
The response rates for indicators that were based on register data were lower, especially for the proportion of HIV-infected pregnant women who started contraception after delivery (Indicator 20), which relied on the post-natal care register
Summary
The effects of two interventions, Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS), were tested on 23 facility performance indicators for emergency triage assessment and treatment (ETAT), malaria, pneumonia, tuberculosis, and HIV. One of seven principles of the United States’ Global Health Initiative is to ‘‘increase impact through strategic coordination and integration.’’ [2] One of four principles of the United Nations Program on HIV/AIDS’ Countdown to Zero initiative is ‘‘leveraging synergies, linkages and integration for improved sustainability.’’ [3] One of nine principles of the joint World Health Organization/United Nations Program on AIDS’ Treatment 2.0 framework is ‘‘decentralization and integration.’’ [4] A recent Cochrane review did not identify any randomized controlled trials of interventions to integrate HIV services with other services for women and children [5]. The evaluation of the Integrated Management of Childhood Illness training program in Uganda emphasized the effects of supervision visits on quality of care [10] and contributed to increasing interest in educational outreach interventions. Educational outreach trips to facilities can be expensive and potentially duplicative if each vertical program conducts them independently
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