Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.
BACKGROUND
Classroom-based learning is often insufficient to ensure high quality care and application of health care guidelines. Educational outreach is garnering attention as a supplemental method to enhance health care worker capacity, yet there is little information about the timing and duration required to improve facility performance. We sought to evaluate the effects of an infectious disease training program followed by either immediate or delayed on-site support (OSS), an educational outreach approach, on nine facility performance indicators for emergency triage, assessment, and treatment; malaria; and pneumonia. We also compared the effects of nine monthly OSS visits to extended OSS, with three additional visits over six months.


METHODS
This study was conducted at 36 health facilities in Uganda, covering 1,275,960 outpatient visits over 23 months. From April 2010 to December 2010, 36 sites received infectious disease training; 18 randomly selected sites in arm A received nine monthly OSS visits (immediate OSS) and 18 sites in arm B did not. From March 2011 to September 2011, arm A sites received three additional visits every two months (extended OSS), while the arm B sites received eight monthly OSS visits (delayed OSS). We compared the combined effect of training and delayed OSS to training followed by immediate OSS to determine the effect of delaying OSS implementation by nine months. We also compared facility performance in arm A during the extended OSS to immediate OSS to examine the effect of additional, less frequent OSS.


RESULTS
Delayed OSS, when combined with training, was associated with significant pre/post improvements in four indicators: outpatients triaged (44% vs. 87%, aRR = 1.54, 99% CI = 1.11, 2.15); emergency and priority patients admitted, detained, or referred (16% vs. 31%, aRR = 1.74, 99% CI = 1.10, 2.75); patients with a negative malaria test result prescribed an antimalarial (53% vs. 34%, aRR = 0.67, 99% CI = 0.55, 0.82); and pneumonia suspects assessed for pneumonia (6% vs. 27%, aRR = 2.97, 99% CI = 1.44, 6.17). Differences between the delayed OSS and immediate OSS arms were not statistically significant for any of the nine indicators (all adjusted relative RR (aRRR) between 0.76-1.44, all p>0.06). Extended OSS was associated with significant improvement in two indicators (outpatients triaged: aRR = 1.09, 99% CI = 1.01; emergency and priority patients admitted, detained, or referred: aRR = 1.22, 99% CI = 1.01, 1.38) and decline in one (pneumonia suspects assessed for pneumonia: aRR: 0.93; 99% CI = 0.88, 0.98).


CONCLUSIONS
Educational outreach held up to nine months after training had similar effects on facility performance as educational outreach started within one month post-training. Six months of bi-monthly educational outreach maintained facility performance gains, but incremental improvements were heterogeneous.
Accordia Global Health Foundation, Washington, District of Columbia, United States of America.
Sarah M
SM
Burnett
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
Martin K
MK
Mbonye
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
Sarah
S
Naikoba
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
Stella
S
Zawedde-Muyanja
Center for Human Services, University Research Co. LLC, Bethesda, MD, United States of America.
Stephen N
SN
Kinoti
Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
Allan
A
Ronald
Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
Timothy
T
Rubashembusya
Accordia Global Health Foundation, Washington, District of Columbia, United States of America.
Kelly S
KS
Willis
Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
Robert
R
Colebunders
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
Yukari C
YC
Manabe
International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, Washington, United States of America.
Marcia R
MR
Weaver
D003141:Communicable Diseases / Q000628:therapy*; D004501:Education, Medical / Q000379:methods*; D019983:Guideline Adherence; D006268:Health Facilities; D006282:Health Personnel / Q000193:education*; D006801:Humans; D013997:Time Factors; D014454:Uganda