title: The effect of pre-service training on post-graduation skill and knowledge retention among mid-level healthcare providers in Mozambique.
abstract: BACKGROUND
  Mozambique suffers from critical shortages of healthcare workers including non-physician clinicians, Tecnicos de Medicina Geral (TMGs), who are often senior clinicians in rural health centres. The Mozambique Ministry of Health and the International Training and Education Center for Health, University of Washington, Seattle, revised the national curriculum to improve TMG clinical knowledge and skills. To evaluate the effort, data was collected at graduation and 10 months later from pre-revision (initial) and revised curriculum TMGs to determine the following: (1) Did cohorts trained in the revised curriculum score higher on measurements of clinical knowledge, physical exam procedures, and solving clinical case scenarios than those trained in the initial curriculum; (2) Did TMGs in both curricula retain their knowledge over time (from baseline to follow-up); and (3) Did skills and knowledge retention differ over time by curricula? Post-graduation and over time results are presented.
  
  
  METHODS
  t-tests examine differences in scores between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related, demographic, and workplace factors associated with scores on each of three evaluation methods at the p < 0.05 level. Paired t-tests examine within-group changes over time. ANOVA models explore differences between Health Training Institutes (HTIs). Generalized estimating equations determine whether change in scores over time differed by curricula.
  
  
  RESULTS
  Mean scores of initial curriculum TMGs at follow-up were 52.7%, 62.6%, and 40.0% on the clinical cases, knowledge test, and physical exam, respectively. Averages were significantly higher among the revised group for clinical cases (60.2%; p < 0.001) and physical exam (47.6%; p < 0.001). HTI was influential on clinical case and physical exam scores. Between graduation and follow-up, clinical case and physical exam scores decreased significantly for initial curriculum students; clinical case scores increased significantly among revised curriculum TMGs.
  
  
  CONCLUSIONS
  Although curriculum revision had limited effect, marginal improvements in the revised group show promise that these TMGs may have increased ability to synthesize clinical information. Weaknesses in curriculum and practicum implementation likely compromised the effect of curriculum revision. An improvement strategy that includes strengthened TMG training, greater attention to pre-service clinical practice, and post-graduation mentoring may be more advantageous than curriculum revision, alone, to improve care provided by TMGs.
authors.affiliation: International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, USA. cfeld@uw.edu.|Department of Global Health, University of Washington, 901 Boren Avenue, Suite 1100, Seattle, 98104, WA, USA. cfeld@uw.edu.
authors.forename: Caryl
authors.initials: C
authors.lastname: Feldacker
authors.affiliation: National Institute of Health, Mozambique Ministry of Health, Maputo, Mozambique. chicumbe@gmail.com.
authors.forename: Sergio
authors.initials: S
authors.lastname: Chicumbe
authors.affiliation: Department of Human Resources, Mozambique Ministry of Health, Maputo, Mozambique. martinho.dgedge@gmail.com.
authors.forename: Martinho
authors.initials: M
authors.lastname: Dgedge
authors.affiliation: International Training and Education Center for Health (I-TECH), Maputo, Mozambique. freidec@itech-mozambique.org.
authors.forename: Freide
authors.initials: F
authors.lastname: Cesar
authors.affiliation: International Training and Education Center for Health (I-TECH), Maputo, Mozambique. geritoa@itech-mozambique.org.
authors.forename: Gerito
authors.initials: G
authors.lastname: Augusto
authors.affiliation: International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, USA. mollyrobe@gmail.com.
authors.forename: Molly
authors.initials: M
authors.lastname: Robertson
authors.affiliation: National Institute of Health, Mozambique Ministry of Health, Maputo, Mozambique. mbofana98@yahoo.com.
authors.forename: Francisco
authors.initials: F
authors.lastname: Mbofana
authors.affiliation: International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, USA. gomalley@uw.edu.|Department of Global Health, University of Washington, 901 Boren Avenue, Suite 1100, Seattle, 98104, WA, USA. gomalley@uw.edu.
authors.forename: Gabrielle
authors.initials: G
authors.lastname: O'Malley
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D002983:Clinical Competence; D003479:Curriculum; D003695:Delivery of Health Care; D004504:Education, Medical, Undergraduate; D004521:Educational Measurement; D005260:Female; D006282:Health Personnel / Q000193:education*; D006801:Humans; D007391:International Cooperation; D008297:Male; D009073:Mozambique; D019035:Rural Health Services; D000078329:Workforce