title: Effectiveness of educational outreach in infectious diseases management: a cluster randomized trial in Uganda.
abstract: 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. 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).
  
  
  
  Thirty-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).
  
  
  
  The 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).
  
  
  
  Effects 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.
authors.affiliation: Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda. mbonyemarti@yahoo.com.|School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda. mbonyemarti@yahoo.com.|Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium. mbonyemarti@yahoo.com.
authors.forename: Martin Kayitale
authors.initials: MK
authors.lastname: Mbonye
authors.affiliation: Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.|Accordia Global Health Foundation, Washington, DC, USA.|PATH, Washington, DC, USA.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Burnett
authors.affiliation: Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.|Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.|Save the Children, Kampala, Uganda.
authors.forename: Sarah
authors.initials: S
authors.lastname: Naikoba
authors.affiliation: Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Allan
authors.initials: A
authors.lastname: Ronald
authors.affiliation: Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.|Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Robert
authors.initials: R
authors.lastname: Colebunders
authors.affiliation: Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Van Geertruyden
authors.affiliation: Department of Global Health, University of Washington, International Training and Education Center for Health (I-TECH), Seattle, WA, USA.|Department of Global Health, University of Washington, Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Marcia R
authors.initials: MR
authors.lastname: Weaver
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000962:Antimalarials / Q000627:therapeutic use; D057191:Capacity Building; D019090:Case Management; D003140:Communicable Disease Control; D003141:Communicable Diseases / Q000628:therapy*; D020375:Education, Distance; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy; D006268:Health Facilities; D006282:Health Personnel / Q000193:education*; D006801:Humans; D017053:Infection Control; D007318:Inservice Training; D008288:Malaria / Q000175:diagnosis / Q000188:drug therapy; D011014:Pneumonia / Q000175:diagnosis / Q000188:drug therapy; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000188:drug therapy; D016896:Treatment Outcome; D014218:Triage; D014454:Uganda; D016526:Workload
chemical_list: D000900:Anti-Bacterial Agents; D000962:Antimalarials
keywords: Classroom training; Educational outreach; Mid-level health providers; Uganda