A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results

Evaluating the implementation of the Pediatric Acute Care Education (PACE) program in northwestern Tanzania: a mixed-methods study guided by normalization process theory

BACKGROUND

In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania's guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown.

OBJECTIVES

(1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential.

METHODS

Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs).

RESULTS

Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study's focus on PACE's initial implementation.

CONCLUSION

This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

Improving interprofessional collaboration: building confidence using a novel HIV curriculum for healthcare workers across sub-Saharan africa

The 21st century presents significant global health challenges that necessitate an integrated health workforce capable of delivering person-centered and integrated healthcare services. Interprofessional collaboration (IPC) plays a vital role in achieving integration and training an IPC-capable workforce in sub-Saharan Africa (SSA) has become imperative. This study aims to assess changes in IPC confidence among learners participating in a team-based, case-based HIV training programme across diverse settings in SSA. Additionally, it sought to examine the impact of different course formats (in-person, synchronous virtual, or blended learning) on IPC confidence. Data from 20 institutions across 18 SSA countries were collected between May 1 and December 31, 2021. Logistic regression analysis was conducted to estimate associations between variables of interest and the increases in IPC confidence. The analysis included 3,842 learners; nurses comprised 37.9% (n = 1,172) and physicians 26.7% (n = 825). The majority of learners (67.2%, n = 2,072) were pre-service learners, while 13.0% (n = 401) had graduated within the past year. Factors significantly associated with increased IPC confidence included female gender, physician cadre, completion of graduate training over 12 months ago, and participation in virtual or in-person synchronous workshops (p < .05). The insights from this analysis can inform future curriculum development to strengthen interprofessional healthcare delivery across SSA.

The medical competence of health care providers in sub-Saharan Africa: Evidence from 16 127 providers across 11 countries

Despite a consensus that quality of care is critically deficient in low-income countries, few nationally representative studies provide comparable measures of quality of care across countries. To address this gap, we used nationally representative data from in-person administrations of clinical vignettes to measure the competence of 16 127 health care providers across 11 sub-Saharan African countries. Rather than large variations across countries, we found that 81% of the variation in competence is within countries and the characteristics of health care providers do not explain most of this variation. Professional qualifications-including cadre and education-are only weakly associated with competence: across our sample, one-third of nurses are more competent than the average doctor in the same country and one-quarter of doctors are less competent than the average nurse. Finally, while younger cohorts do tend to be more competent, perhaps reflecting improvements in medical education, it would take 25 decades of turnover to improve care by 10 percentage points, on average, if we were to rely on such improvements alone. These patterns necessitate a fundamentally different approach to health care human resource management, calling into question typical staffing policies based on qualifications and seniority rather than directly measured quality.

Evaluating the Implementation of the Pediatric Acute Care Education (PACE) Program in Northwestern Tanzania: A Mixed-Methods Study Guided by Normalization Process Theory

Background

In low- and -middle-income countries (LMICs) like Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this, we introduced PACE (Pediatric Acute Care Education), an adaptive e-learning program tailored to enhance provider competency in line with Tanzania's national guidelines for managing seriously ill children. Adaptive e-learning presents a promising alternative to traditional in-service education, yet optimal strategies for its implementation in LMIC settings remain to be fully elucidated.

Objectives

This study aimed to (1) evaluate the initial implementation of PACE in Mwanza, Tanzania, using the constructs of Normalization Process Theory (NPT), and (2) provide insights into its feasibility, acceptability, and scalability potential.

Methods

A mixed-methods approach was employed across three healthcare settings in Mwanza: a zonal hospital and two health centers. NPT was utilized to navigate the complexities of implementing PACE. Data collection involved a customized NoMAD survey, focus groups and in-depth interviews with healthcare providers.

Results

The study engaged 82 healthcare providers through the NoMAD survey and 79 in focus groups and interviews. Findings indicated high levels of coherence and cognitive participation, demonstrating that PACE is well-understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practice, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly affecting collective action, were noted. The short duration of the study limited the assessment of reflexive monitoring, though early indicators point towards the potential for PACE's long-term sustainability.

Conclusion

This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges is crucial for its successful and sustainable implementation. Furthermore, the study underscores the value of NPT as a framework in guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo

In sub-Saharan African settings like the Democratic Republic of the Congo, high-quality care during childbirth and the immediate postpartum period is lacking in public facilities, necessitating multipronged interventions to improve care. We used a pre-post design to examine the effectiveness of a low-dose, high-frequency capacity-building and quality improvement (QI) intervention to improve care for women and newborns around the day of birth in 16 health facilities in Kinshasa, Democratic Republic of the Congo. Effectiveness was assessed based on changes in provider skills, key health indicators, and beneficiary satisfaction. To assess changes in the competency of the 188 providers participating in the intervention, we conducted objective structured clinical examinations on care for mothers and newborns on the day of birth, immediate postpartum family planning (PPFP) counseling and method provision, and postabortion care before and after implementation of training and at 6 and 12 months after training. Interrupted time series (ITS) analysis techniques were used to analyze routine health service data for changes in select maternal, newborn, and postpartum outcomes before and after the intervention. To assess changes in clients' perceptions of care, 2 rounds of telephone surveys were administered. Before the intervention, less than 2% of participating providers demonstrated competency in skills. Immediately after training, more than 80% demonstrated competency, and 70% retained competency after 12 months. ITS analyses show the risk of early neonatal death declined significantly by 9% (95% confidence interval [CI]=4%, 13%, P<.001), and likelihood of immediate PPFP uptake increased significantly by 72% (95% CI=53%, 92%, P<.001). Client satisfaction improved by 58% over the life of the project. These findings build on previous studies documenting the effectiveness of clinical capacity-building and QI approaches. If implemented at scale, this approach has the potential to substantively contribute to improving maternal and perinatal health in similar settings.

Barriers and enablers for implementation of digital-linked diagnostics models at point-of-care in South Africa: stakeholder engagement

The integration of digital technologies holds significant promise in enhancing accessibility to disease diagnosis and treatment at point-of-care (POC) settings. Effective implementation of such interventions necessitates comprehensive stakeholder engagements. This study presents the outcomes of a workshop conducted with key stakeholders, aiming to discern barriers and enablers in implementing digital-connected POC diagnostic models in South Africa. The workshop, a component of the 2022 REASSURED Diagnostics symposium, employed the nominal group technique (NGT) and comprised two phases: Phase 1 focused on identifying barriers, while Phase 2 centered on enablers for the implementation of digital-linked POC diagnostic models. Stakeholders identified limited connectivity, restricted offline functionality, and challenges related to load shedding or rolling electricity blackouts as primary barriers. Conversely, ease of use, subsidies provided by the National Health Insurance, and 24-h assistance emerged as crucial enablers for the implementation of digital-linked POC diagnostic models. The NGT workshop proved to be an effective platform for elucidating key barriers and enablers in implementing digital-linked POC diagnostic models. Subsequent research endeavors should concentrate on identifying optimal strategies for implementing these advanced diagnostic models in underserved populations.

Implementing adaptive e-learning for newborn care in Tanzania: an observational study of provider engagement and knowledge gains

INTRODUCTION

To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment. The objectives of this study were to (1) assess implementation success with use of in-person support and nudging strategy and (2) describe baseline provider knowledge and metacognition.

METHODS

6-month observational study at one zonal hospital and three health centres in Mwanza, Tanzania. To assess implementation success, we used the Reach, Efficacy, Adoption, Implementation and Maintenance framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity.

RESULTS

aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centres. Median clinical experience was 4 years (IQR 1-9) and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD ±17%). Providers averaged 78% (SD ±31%) completion of initial learning and 7% (SD ±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% (IQR: 38%-63%), unconscious-incompetence 32% (IQR: 23%-42%), conscious-incompetence 7% (IQR: 2%-15%), and unconscious-competence 2% (IQR: 0%-3%). Higher baseline conscious-competence (OR 31.6 (95% CI 5.8 to 183.5)) and being a nursing officer (aOR: 5.6 (95% CI 1.8 to 18.1)), compared with medical officer, were associated with initial learning completion or persistent activity.

CONCLUSION

aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalisation is needed.

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research 'cycles' designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach 'key populations' at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy.

Comparing in-person, blended and virtual training interventions; a real-world evaluation of HIV capacity building programs in 16 countries in sub-Saharan Africa

We sought to evaluate the impact of transitioning a multi-country HIV training program from in-person to online by comparing digital training approaches implemented during the pandemic with in-person approaches employed before COVID-19. We evaluated mean changes in pre-and post-course knowledge scores and self-reported confidence scores for learners who participated in (1) in-person workshops (between October 2019 and March 2020), (2) entirely asynchronous, Virtual Workshops [VW] (between May 2021 and January 2022), and (3) a blended Online Course [OC] (between May 2021 and January 2022) across 16 SSA countries. Learning objectives and evaluation tools were the same for all three groups. Across 16 SSA countries, 3023 participants enrolled in the in-person course, 2193 learners participated in the virtual workshop, and 527 in the online course. The proportions of women who participated in the VW and OC were greater than the proportion who participated in the in-person course (60.1% and 63.6%, p<0.001). Nursing and midwives constituted the largest learner group overall (1145 [37.9%] vs. 949 [43.3%] vs. 107 [20.5%]). Across all domains of HIV knowledge and self-perceived confidence, there was a mean increase between pre- and post-course assessments, regardless of how training was delivered. The greatest percent increase in knowledge scores was among those participating in the in-person course compared to VW or OC formats (13.6% increase vs. 6.0% and 7.6%, p<0.001). Gains in self-reported confidence were greater among learners who participated in the in-person course compared to VW or OC formats, regardless of training level (p<0.001) or professional cadre (p<0.001). In this multi-country capacity HIV training program, in-person, online synchronous, and blended synchronous/asynchronous strategies were effective means of training learners from diverse clinical settings. Online learning approaches facilitated participation from more women and more diverse cadres. However, gains in knowledge and clinical confidence were greater among those participating in in-person learning programs.

Feasibility of an Adaptive E-Learning Environment to Improve Provider Proficiency in Essential and Sick Newborn Care in Mwanza, Tanzania

Introduction

To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment (AEE). The objectives of this study were to 1) assess implementation success with use of in-person support and nudging strategy and 2) describe baseline provider knowledge and metacognition.

Methods

6-month observational study at 1 zonal hospital and 3 health centers in Mwanza, Tanzania. To assess implementation success, we used the RE-AIM framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity.

Results

aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing, and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centers. Median clinical experience was 4 years [IQR 1,9] and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD±17%). Providers averaged 78% (SD±31%) completion of initial learning and 7%(SD±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% [IQR:38-63%], unconscious-incompetence 32% [IQR:23-42%], conscious-incompetence 7% [IQR:2-15%], and unconscious-competence 2% [IQR:0-3%]. Higher baseline conscious-competence (OR 31.6 [95%CI:5.8, 183.5) and being a nursing officer (aOR: 5.6 [95%CI:1.8, 18.1]), compared to medical officer) were associated with initial learning completion or persistent activity.

Conclusion

aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning, and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalization is needed.

Development of pediatric acute care education (PACE): An adaptive electronic learning (e-learning) environment for healthcare providers in Tanzania

Globally, inadequate healthcare provider (HCP) proficiency with evidence-based guidelines contributes to millions of newborn, infant, and child deaths each year. HCP guideline proficiency would improve patient outcomes. Conventional (in person) HCP in-service education is limited in 4 ways: reach, scalability, adaptability, and the ability to contextualize. Adaptive e-learning environments (AEE), a subdomain of e-learning, incorporate artificial intelligence technology to create a unique cognitive model of each HCP to improve education effectiveness. AEEs that use existing internet access and personal mobile devices may overcome limits of conventional education. This paper provides an overview of the development of our AEE HCP in-service education, Pediatric Acute Care Education (PACE). PACE uses an innovative approach to address HCPs' proficiency in evidence-based guidelines for care of newborns, infants, and children. PACE is novel in 2 ways: 1) its patient-centric approach using clinical audit data or frontline provider input to determine content and 2) its ability to incorporate refresher learning over time to solidify knowledge gains. We describe PACE's integration into the Pediatric Association of Tanzania's (PAT) Clinical Learning Network (CLN), a multifaceted intervention to improve facility-based care along a single referral chain. Using principles of co-design, stakeholder meetings modified PACE's characteristics and optimized integration with CLN. We plan to use three-phase, mixed-methods, implementation process. Phase I will examine the feasibility of PACE and refine its components and protocol. Lessons gained from this initial phase will guide the design of Phase II proof of concept studies which will generate insights into the appropriate empirical framework for (Phase III) implementation at scale to examine effectiveness.

The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions

Introduction

Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes.

Methods

We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices.

Results

The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings.

Conclusion

The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.

How does the effectiveness of strategies to improve healthcare provider practices in low-income and middle-income countries change after implementation? Secondary analysis of a systematic review

BACKGROUND

A recent systematic review evaluated the effectiveness of strategies to improve healthcare provider (HCP) performance in low-income and middle-income countries. The review identified strategies with varying effects, including in-service training, supervision and group problem-solving. However, whether their effectiveness changed over time remained unclear. In particular, understanding whether effects decay over time is crucial to improve sustainability.

METHODS

We conducted a secondary analysis of data from the aforementioned review to explore associations between time and effectiveness. We calculated effect sizes (defined as percentage-point (%-point) changes) for HCP practice outcomes (eg, percentage of patients correctly treated) at each follow-up time point after the strategy was implemented. We estimated the association between time and effectiveness using random-intercept linear regression models with time-specific effect sizes clustered within studies and adjusted for baseline performance.

RESULTS

The primary analysis included 37 studies, and a sensitivity analysis included 77 additional studies. For training, every additional month of follow-up was associated with a 0.19 %-point decrease in effectiveness (95% CI: -0.36 to -0.03). For training combined with supervision, every additional month was associated with a 0.40 %-point decrease in effectiveness (95% CI: -0.68 to -0.12). Time trend results for supervision were inconclusive. For group problem-solving alone, time was positively associated with effectiveness, with a 0.50 %-point increase in effect per month (95% CI: 0.37 to 0.64). Group problem-solving combined with training was associated with large improvements, and its effect was not associated with time.

CONCLUSIONS

Time trends in the effectiveness of different strategies to improve HCP practices vary among strategies. Programmes relying solely on in-service training might need periodical refresher training or, better still, consider combining training with group problem-solving. Although more high-quality research is needed, these results, which are important for decision-makers as they choose which strategies to use, underscore the utility of studies with multiple post-implementation measurements so sustainability of the impact on HCP practices can be assessed.

The effectiveness of supervision strategies to improve health care provider practices in low- and middle-income countries: secondary analysis of a systematic review

BACKGROUND

Although supervision is a ubiquitous approach to support health programs and improve health care provider (HCP) performance in low- and middle-income countries (LMICs), quantitative evidence of its effects is unclear. The objectives of this study are to describe the effect of supervision strategies on HCP practices in LMICs and to identify attributes associated with greater effectiveness of routine supervision.

METHODS

We performed a secondary analysis of data on HCP practice outcomes (e.g., percentage of patients correctly treated) from a systematic review on improving HCP performance. The review included controlled trials and interrupted time series studies. We described distributions of effect sizes (defined as percentage-point [%-point] changes) for each supervision strategy. To identify attributes associated with supervision effectiveness, we performed random-effects linear regression modeling and examined studies that directly compared different approaches of routine supervision.

RESULTS

We analyzed data from 81 studies from 36 countries. For professional HCPs, such as nurses and physicians, primarily working at health facilities, routine supervision (median improvement when compared to controls: 10.7%-points; IQR: 9.9, 27.9) had similar effects on HCP practices as audit with feedback (median improvement: 10.1%-points; IQR: 6.2, 23.7). Two attributes were associated with greater mean effectiveness of routine supervision (p < 0.10): supervisors received supervision (by 8.8-11.5%-points), and supervisors participated in problem-solving with HCPs (by 14.2-20.8%-points). Training for supervisors and use of a checklist during supervision visits were not associated with effectiveness. The effects of supervision frequency (i.e., number of visits per year) and dose (i.e., the number of supervision visits during a study) were unclear. For lay HCPs, the effect of routine supervision was difficult to characterize because few studies existed, and effectiveness in those studies varied considerably. Evidence quality for all findings was low primarily because many studies had a high risk of bias.

CONCLUSIONS

Although evidence is limited, to promote more effective supervision, our study supports supervising supervisors and having supervisors engage in problem-solving with HCPs. Supervision's integral role in health systems in LMICs justifies a more deliberate research agenda to identify how to deliver supervision to optimize its effect on HCP practices.

Private sector delivery of maternal and newborn health care in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

Recent studies have pointed to the substantial role of private health sector delivery of maternal and newborn health (MNH) care in low-/middle-income countries (LMICs). While this role has been partly documented, an evidence synthesis is missing. To analyse opportunities and challenges of private sector delivery of MNH care as they pertain to the new World Health Organization (WHO) strategy on engaging the private health service delivery sector through governance in mixed health systems, a more granular understanding of the private health sector's role and extent in MNH delivery is imperative. We developed a scoping review protocol to map and conceptualise interventions that were explicitly designed and implemented by formal private health sector providers to deliver MNH care in mixed health systems.

METHODS AND ANALYSIS

This protocol details our intended methodological and analytical approach following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Seven databases (Cumulative Index to Nursing and Allied Health, Excerpta Medica Database, International Bibliography of the Social Sciences, PubMed, ScienceDirect, Web of Science, WHO Institutional Repository for Information Sharing) and two websites will be searched for studies published between 1 January 2002 and 1 June 2021. For inclusion, quantitative and/or qualitative studies in LMICs must report at least one of the following outcomes: maternal morbidity or mortality; newborn morbidity or mortality; experience of care; use of formal private sector care during pregnancy, childbirth, and postpartum; and stillbirth. Analyses will synthesise the evidence base and gaps on private sector MNH service delivery interventions for each of the six governance behaviours.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be used to develop a menu of private sector interventions for MNH care by governance behaviour. This study will be disseminated through a peer-reviewed publication, working groups, webinars and partners.

A Quality Improvement Intervention to Inform Scale-Up of Integrated HIV-TB Services: Lessons Learned From KwaZulu-Natal, South Africa

INTRODUCTION

In South Africa, mortality rates among HIV-TB coinfected patients are among the highest in the world. The key to reducing mortality is integrating HIV-TB services, however, a generalizable implementation method and package of tested change ideas to guide the scale-up of integrated HIV-TB services are unavailable. We describe the implementation of a quality improvement (QI) intervention, health systems' weaknesses, change ideas, and lessons learned in improving integrated HIV-TB services.

METHODS

Between December 1, 2016, and December 31, 2018, 8 nurse supervisors overseeing 20 primary health care (PHC) clinics formed a learning collaborative to improve a set of HIV-TB process indicators. HIV-TB process indicators comprised: HIV testing services (HTS), TB screening among PHC clinic attendees, isoniazid preventive therapy (IPT) for eligible HIV patients, antiretroviral therapy (ART) for HIV-TB coinfected patients, and viral load (VL) testing at month 12. Routine HIV-TB process data were collected and analyzed.

RESULTS

Key change interventions, generated by health care workers, included: patient-flow redesign, daily data quality checks; prior identification of patients eligible for IPT and VL testing. Between baseline and post-QI intervention, IPT initiation rates increased from 15.9% to 76.4% (P=.019), HTS increased from 84.8% to 94.5% (P=.110), TB screening increased from 76.2% to 85.2% (P=.040), and VL testing increased from 61.4% to 74.0% (P=.045). ART initiation decreased from 95.8% to 94.1% (P=.481).

DISCUSSION

Although integrating HIV-TB services is standard guidance, existing process gaps to achieve integration can be closed using QI methods. QI interventions can rapidly improve the performance of processes, particularly if baseline performance is low. Improving data quality enhances the success of QI initiatives.

Development, characteristics and impact of quality improvement casebooks: a scoping review

BACKGROUND

Quality improvement (QI) casebooks, compilations of QI experiences, are one way to share experiential knowledge that healthcare policy-makers, managers and professionals can adapt to their own contexts. However, QI casebook use, characteristics and impact are unknown. We aimed to synthesize published research on QI prevalence, development, characteristics and impact.

METHODS

We conducted a scoping review by searching MEDLINE, EMBASE, CINAHL and SCOPUS from inception to 4 February 2021. We extracted data on study characteristics and casebook definitions, development, characteristics (based on the WIDER [Workgroup for Intervention Development and Evaluation Research] framework) and impact. We reported findings using summary statistics, text and tables.

RESULTS

We screened 2999 unique items and included five articles published in Canada from 2011 to 2020 describing three studies. Casebooks focused on promoting positive weight-related conversations with children and parents, coordinating primary care-specialist cancer management, and showcasing QI strategies for cancer management. All defined casebooks similarly described real-world experiences of developing and implementing QI strategies that others could learn from, emulate or adapt. In all studies, casebook development was a multistep, iterative, interdisciplinary process that engages stakeholders in identifying, creating and reviewing content. While casebooks differed in QI topic, level of application and scope, cases featured common elements: setting or context, QI strategy details, impacts achieved, and additional tips for implementing strategies. Cases were described with a blend of text, graphics and tools. One study evaluated casebook impact, and found that it enhanced self-efficacy and use of techniques to improve clinical care. Although details about casebook development and characteristics were sparse, we created a template of casebook characteristics, which others can use as the basis for developing or evaluating casebooks.

CONCLUSION

Future research is needed to optimize methods for developing casebooks and to evaluate their impact. One approach is to assess how the many QI casebooks available online were developed. Casebooks should be evaluated alone or in combination with other interventions that support QI on a range of outcomes.

Process evaluation of an implementation strategy to support uptake of a tuberculosis treatment adherence intervention to improve TB care and outcomes in Malawi

OBJECTIVE

To assess implementation and to identify barriers and facilitators to implementation, sustainability and scalability of an implementation strategy to provide lay health workers (LHWs) with the knowledge, skills and tools needed to implement an intervention to support patient tuberculosis (TB) treatment adherence.

DESIGN

Mixed-methods design including a cluster randomised controlled trial and process evaluation informed by the RE-AIM framework.

SETTING

Forty-five health centres (HCs) in four districts in the south east zone of Malawi, who had an opportunity to receive cascade training.

PARTICIPANTS

Forty-five peer-trainers (PTs), 23 patients and 20 LHWs.

INTERVENTION

Implementation strategy employing peer-led educational outreach, a clinical support tool and peer support network to implement a TB treatment adherence intervention.

OUTCOME MEASURES

Process data were collected from study initiation to the end-of-study PT meeting, and included: LHW and patient interviews, quarterly PT meeting notes, training logs and study team observations and meeting notes. Data sources were first analysed in isolation, followed by method, data source and analyst triangulation. Analyses were conducted independently by two study team members, and themes revised through discussion and involvement of additional study team members as needed.

RESULTS

Forty-one HCs (91%) trained at least one LHW. Of 256 LHWs eligible to participate at study start 152 (59%) completed training, with the proportion trained per HC ranging from 0% to 100% at the end of initial cascade training. Lack of training incentives was the primary barrier to implementation, with intrinsic motivation to improve knowledge and skills, and to improve patient care and outcomes the primary facilitators of participation.

CONCLUSION

We identified important challenges to and potential facilitators of implementation, scalability and sustainability, of the TB treatment adherence intervention. Findings provide guidance to scale-up, and use of the implementation strategies employed, to address LHW training and supervision in other areas.

TRIAL REGISTRATION NUMBER

NCT02533089.

Performance management in complex adaptive systems: a conceptual framework for health systems

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

Facility standards and the quality of public sector primary care: Evidence from South Africa's "Ideal Clinics" program

Primary healthcare systems are central to achieving universal healthcare coverage. However, in many low- and middle-income country settings, primary care quality is challenged by inadequate facility infrastructure and equipment, limited human resources, and poor provider process. We study the effects of a recent large-scale quality improvement policy in South Africa, the Ideal Clinics Realization and Maintenance Program (ICRMP). The ICRMP introduced a set of standards for facilities and a quality improvement process involving manuals, district-based support, and external assessment. Exploiting differential prioritization of facilities for the ICRMP's quality improvement process, we apply differences-in-differences methods to identify the effects of the program's efforts on standards scores and primary care quality indicators over the first 12 months of implementation. We find large and statistically significant increases in standards scores, but mixed effects on care outcomes-a small magnitude improvement in early antenatal care usage, null effects on childhood immunization and cervical cancer screening, and small negative effect of human immunodeficiency virus (HIV) care. While the ICRMP process has led to significant improvements in facilities' satisfaction of the program's standards, we were unable to detect meaningful change in care quality indicators.

Surgical data strengthening in Ethiopia: results of a Kirkpatrick framework evaluation of a data quality intervention

Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia.

Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals.

Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up.

Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure.

Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from −1.77 to −1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

The effectiveness of training strategies to improve healthcare provider practices in low-income and middle-income countries

INTRODUCTION

In low/middle-income countries (LMICs), training is often used to improve healthcare provider (HCP) performance. However, important questions remain about how well training works and the best ways to design training strategies. The objective of this study is to characterise the effectiveness of training strategies to improve HCP practices in LMICs and identify attributes associated with training effectiveness.

METHODS

We performed a secondary analysis of data from a systematic review on improving HCP performance. The review included controlled trials and interrupted time series, and outcomes measuring HCP practices (eg, percentage of patients correctly treated). Distributions of effect sizes (defined as percentage-point (%-point) changes) were described for each training strategy. To identify effective training attributes, we examined studies that directly compared training approaches and performed random-effects linear regression modelling.

RESULTS

We analysed data from 199 studies from 51 countries. For outcomes expressed as percentages, educational outreach visits (median effect size when compared with controls: 9.9 %-points; IQR: 4.3-20.6) tended to be somewhat more effective than in-service training (median: 7.3 %-points; IQR: 3.6-17.4), which seemed more effective than peer-to-peer training (4.0 %-points) and self-study (by 2.0-9.3 %-points). Mean effectiveness was greater (by 6.0-10.4 %-points) for training that incorporated clinical practice and training at HCPs' work site. Attributes with little or no effect were: training with computers, interactive methods or over multiple sessions; training duration; number of educational methods; distance training; trainers with pedagogical training and topic complexity. For lay HCPs, in-service training had no measurable effect. Evidence quality for all findings was low.

CONCLUSIONS

Although additional research is needed, by characterising the effectiveness of training strategies and identifying attributes of effective training, decision-makers in LMICs can improve how these strategies are selected and implemented.

Improving case detection of tuberculosis in hospitalised Kenyan children-employing the behaviour change wheel to aid intervention design and implementation

BACKGROUND

The true burden of tuberculosis in children remains unknown, but approximately 65% go undetected each year. Guidelines for tuberculosis clinical decision-making are in place in Kenya, and the National Tuberculosis programme conducts several trainings on them yearly. By 2018, there were 183 GeneXpert® machines in Kenyan public hospitals. Despite these efforts, diagnostic tests are underused and there is observed under detection of tuberculosis in children. We describe the process of designing a contextually appropriate, theory-informed intervention to improve case detection of TB in children and implementation guided by the Behaviour Change Wheel.

METHODS

We used an iterative process, going back and forth from quantitative and qualitative empiric data to reviewing literature, and applying the Behaviour Change Wheel guide. The key questions reflected on included (i) what is the problem we are trying to solve; (ii) what behaviours are we trying to change and in what way; (iii) what will it take to bring about desired change; (iv) what types of interventions are likely to bring about desired change; (v) what should be the specific intervention content and how should this be implemented?

RESULTS

The following behaviour change intervention functions were identified as follows: (i) training: imparting practical skills; (ii) modelling: providing an example for people to aspire/imitate; (iii) persuasion: using communication to induce positive or negative feelings or stimulate action; (iv) environmental restructuring: changing the physical or social context; and (v) education: increasing knowledge or understanding. The process resulted in a multi-faceted intervention package composed of redesigning of child tuberculosis training; careful selection of champions; use of audit and feedback linked to group problem solving; and workflow restructuring with role specification.

CONCLUSION

The intervention components were selected for their effectiveness (from literature), affordability, acceptability, and practicability and designed so that TB programme officers and hospital managers can be supported to implement them with relative ease, alongside their daily duties. This work contributes to the field of implementation science by utilising clear definitions and descriptions of underlying mechanisms of interventions that will guide others to do likewise in their settings for similar problems.

Perspectives and practices of health workers around diagnosis of paediatric tuberculosis in hospitals in a resource-poor setting - modern diagnostics meet age-old challenges

BACKGROUND

Detection of tuberculosis (TB) in children in Kenya is sub-optimal. Xpert MTB/RIF® assay (Xpert®) has the potential to improve speed of TB diagnosis due to its sensitivity and fast turnaround for results. Significant effort and resources have been put into making the machines widely available in Kenya, but use remains low, especially in children. We set out to explore the reasons for the under-detection of TB and underuse of Xpert® in children, identifying challenges that may be relevant to other newer diagnostics in similar settings.

METHODS

This was an exploratory qualitative study with an embedded case study approach. Data collection involved semi-structured interviews; small-group discussions; key informant interviews; observations of TB trainings, sensitisation meetings, policy meetings, hospital practices; desk review of guidelines, job aides and policy documents. The Capability, Opportunity and Motivation (COM-B) framework was used to interpret emerging themes.

RESULTS

At individual level, knowledge, skill, competence and experience, as well as beliefs and fears impacted on capability (physical & psychological) as well as motivation (reflective) to diagnose TB in children and use diagnostic tests. Hospital level influencers included hospital norms, processes, patient flows and resources which affected how individual health workers attempted to diagnose TB in children by impacting on their capability (physical & psychological), motivation (reflective & automatic) and opportunity (physical & social). At the wider system level, community practices and beliefs, and implementation of TB programme directives impacted some of the decisions that health workers made through capability (psychological), motivation (reflective & automatic) and opportunity (physical).

CONCLUSION

We used comprehensive approaches to identify influencers of TB case detection and use of TB diagnostic tests in children in Kenya. These results are being used to design a contextually-appropriate intervention to improve TB diagnosis, which may be relevant to similar low-resource, high TB burden countries and can be feasibly implemented by the National TB programme.

Human resources for health interventions in high- and middle-income countries: findings of an evidence review

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening.

Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh

BACKGROUND

Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016.

METHODS

This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance.

RESULTS

At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens.

CONCLUSIONS

Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.

Private sector delivery of quality care for maternal, newborn and child health in low-income and middle-income countries: a mixed-methods systematic review protocol

INTRODUCTION

To accelerate progress to reach the sustainable development goals for ending preventable maternal, newborn and child deaths, it is critical that both the public and private health service delivery systems invest in increasing coverage of interventions to sustainably deliver quality care for mothers, newborns and children at scale. Although various approaches have been successful in high-income countries, little is known about how to effectively engage and sustain private sector involvement in delivering quality care in low-income and middle-income countries. Our systematic review will examine private sector implementation of quality care for maternal, newborn and child health (MNCH) and the impact of this care. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline for protocols.

METHODS AND ANALYSIS

Following the PRISMA approach, this systematic review will include quantitative, qualitative and mixed-methods studies addressing the provision of quality MNCH care by private sector providers. Eight databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, Web of Science) and two websites will be searched for relevant studies published between 1 January 1995 and 30 June 2019. For inclusion, studies in low-income and middle-income countries must examine at least one of the following critical outcomes: maternal morbidity or mortality, newborn morbidity or mortality, child morbidity or mortality, quality of care, experience of care and service utilisation. Depending on the data, analyses could include meta-analysis, descriptive quantitative statistics, narrative synthesis and thematic synthesis. Quality will be assessed using tools for qualitative and quantitative studies.

ETHICS AND DISSEMINATION

Formal ethical approval is not required for this research, as the secondary data are not identifiable. Findings from this review will be used to develop models for effective collaboration of the private and public sectors in implementing quality of care for MNCH. In addition to publishing our findings in a peer-reviewed journal, the findings will be shared through the Quality of Care Network, relevant mailing lists, webinars and social media.

PROSPERO REGISTRATION NUMBER

CRD42019143383.

The Knowledge Creation and Transfer Mechanism

This chapter reflects on the relationship between the knowledge mobilisation processes that have contributed to behaviour change at an individual and organisational level. It critiques the traditional emphasis in international development on one-off, formal, foreign-led ‘training’ episodes and contrasts these with the more fluid, bilateral, approach to learning through co-working and mentoring.

Quality of tuberculosis care by pharmacies in low- and middle-income countries: Gaps and opportunities

Pharmacies hold great potential to contribute meaningfully to tuberculosis (TB) control efforts, given their accessibility and extensive utilisation by communities in many high burden countries. Despite this promise, the quality of care provided by pharmacies in these settings for a range of conditions has historically been poor. This paper sets out to conceptualise the key issues surrounding quality of TB care in the low- and middle-income country pharmacy setting; examine the empirical evidence on quality of care; and review the interventions employed to improve this. A number of quality challenges are apparent in relation to anti-TB medicine availability, pharmacopeial quality of anti-TB medicines stocked, pharmacy workers’ knowledge, and management of patients both prior to and following diagnosis. Poor management practices include inadequate questioning of symptomatic patients, lack of referral for testing, over-the-counter sale of anti-TB medication as well as unnecessary and harmful medicines (e.g., antibiotics and steroids), and insufficient counselling. Interventions to improve pharmacy practice in relation to TB control have all fallen under the umbrella of public-private mix (PPM) initiatives, whereby pharmacies are engaged into national TB programmes to improve case detection. These interventions all involved training of pharmacists to refer symptomatic patients for testing and have enjoyed reasonable success, although achieving scale remains a challenge. Future interventions would do well to expand their focus beyond case detection to also improve counselling of patients and inappropriate medicine sales. The lack of pharmacy-specific global guidelines and the regulatory environment were identified as key areas for future attention.

Determinants of uptake of intermittent preventive treatment during pregnancy: a review

Malaria in pregnancy (MiP) contributes to devastating maternal and neonatal outcomes. Coverage of intermittent preventive treatment during pregnancy (IPTp) remains alarmingly low. Data was compiled from MiP programme reviews and performed a literature search on access to and determinants of IPTp. National malaria control and reproductive health (RH) policies may be discordant. Integration may improve coverage. Medication stock-outs are a persistent problem. Quality improvement programmes are often not standardized. Capacity building varies across countries. Community engagement efforts primarily focus on promotion of services. The majority of challenges can be addressed at country level to improve IPTp coverage.

Knowledge acquisition and retention following Saving Children's Lives course for healthcare providers in Botswana: a longitudinal cohort study

OBJECTIVES

Millions of children die every year from serious childhood illnesses. Most deaths are avertable with access to quality care. Saving Children's Lives (SCL) includes an abbreviated high-intensity training (SCL-aHIT) for providers who treat serious childhood illnesses. The objective of this study was to examine the impact of SCL-aHIT on knowledge acquisition and retention of providers.

SETTING

76 participating centres who provide primary and secondary care in Kweneng District, Botswana.

PARTICIPANTS

Doctors and nurses expected by the District Health Management Team to provide initial care to seriously ill children, completed SCL-aHIT between January 2014 and December 2016, submitted demographic data, course characteristics and at least one knowledge assessment.

METHODS

Retrospective, cohort study. Planned and actual primary outcome was adjusted acquisition (change in total knowledge score immediately after training) and retention (change in score at 1, 3 and 6 months), secondary outcomes were pneumonia and dehydration subscores. Descriptive statistics and linear mixed models with random intercept and slope were conducted. Relevant institutional review boards approved this study.

RESULTS

211 providers had data for analysis. Cohort was 91% nurses, 61% clinic/health postbased and 45% pretrained in Integrated Management of Childhood Illness (IMCI). A strong effect of SCL-aHIT was seen with knowledge acquisition (+24.56±1.94, p<0.0001), and loss of retention was observed (-1.60±0.67/month, p=0.018). IMCI training demonstrated no significant effect on acquisition (+3.58±2.84, p=0.211 or retention (+0.20±0.91/month, p=0.824) of knowledge. On average, nurses scored lower than physicians (-19.39±3.30, p<0.0001). Lost to follow-up had a significant impact on knowledge retention (-3.03±0.88/month, p=0.0007).

CONCLUSIONS

aHIT for care of the seriously ill child significantly increased provider knowledge and loss of knowledge occurred over time. IMCI training did not significantly impact overall knowledge acquisition nor retention, while professional status impacted overall score and lost to follow-up impacted retention.