title: Capacity-building and clinical competence in infectious disease in Uganda: a mixed-design study with pre/post and cluster-randomized trial components.
abstract: METHODS
  Best practices for training mid-level practitioners (MLPs) to improve global health-services are not well-characterized. Two hypotheses were: 1) Integrated Management of Infectious Disease (IMID) training would improve clinical competence as tested with a single arm, pre-post design, and 2) on-site support (OSS) would yield additional improvements as tested with a cluster-randomized trial.
  
  
  METHODS
  Thirty-six Ugandan health facilities (randomized 1∶1 to parallel OSS and control arms) enrolled two MLPs each. All MLPs participated in IMID (3-week core course, two 1-week boost sessions, distance learning). After the 3-week course, OSS-arm trainees participated in monthly OSS. Twelve written case scenarios tested clinical competencies in HIV/AIDS, tuberculosis, malaria, and other infectious diseases. Each participant completed different randomly-assigned blocks of four scenarios before IMID (t0), after 3-week course (t1), and after second boost course (t2, 24 weeks after t1). Scoring guides were harmonized with IMID content and Ugandan national policy. Score analyses used a linear mixed-effects model. The primary outcome measure was longitudinal change in scenario scores.
  
  
  RESULTS
  Scores were available for 856 scenarios. Mean correct scores at t0, t1, and t2 were 39.3%, 49.1%, and 49.6%, respectively. Mean score increases (95% CI, p-value) for t0-t1 (pre-post period) and t1-t2 (parallel-arm period) were 12.1 ((9.6, 14.6), p<0.001) and -0.6 ((-3.1, +1.9), p = 0.647) percent for OSS arm and 7.5 ((5.0, 10.0), p<0.001) and 1.6 ((-1.0, +4.1), p = 0.225) for control arm. The estimated mean difference in t1 to t2 score change, comparing arm A (participated in OSS) vs. arm B was -2.2 ((-5.8, +1.4), p = 0.237). From t0-t2, mean scores increased for all 12 scenarios.
  
  
  CONCLUSIONS
  Clinical competence increased significantly after a 3-week core course; improvement persisted for 24 weeks. No additional impact of OSS was observed. Data on clinical practice, facility-level performance and health outcomes will complete assessment of overall impact of IMID and OSS.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01190540.
authors.affiliation: Department of Global Health, University of Washington, Seattle, Washington, United States of America. mweaver@uw.edu
authors.forename: Marcia R
authors.initials: MR
authors.lastname: Weaver
authors.forename: Ian
authors.initials: I
authors.lastname: Crozier
authors.forename: Simon
authors.initials: S
authors.lastname: Eleku
authors.forename: Gyaviira
authors.initials: G
authors.lastname: Makanga
authors.forename: Lydia
authors.initials: L
authors.lastname: Mpanga Sebuyira
authors.forename: Janepher
authors.initials: J
authors.lastname: Nyakake
authors.forename: MaryLou
authors.initials: M
authors.lastname: Thompson
authors.forename: Kelly
authors.initials: K
authors.lastname: Willis
mesh_terms: D000328:Adult; D057191:Capacity Building; D002648:Child; D002983:Clinical Competence; D016000:Cluster Analysis; D020375:Education, Distance; D004502:Education, Medical, Continuing; D015658:HIV Infections / Q000188:drug therapy; D006291:Health Policy; D006302:Health Services Research; D006801:Humans; D055552:Infectious Disease Medicine / Q000193:education / Q000379:methods*; D016014:Linear Models; D008288:Malaria / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D012107:Research Design; D013997:Time Factors; D014376:Tuberculosis / Q000628:therapy*; D014454:Uganda