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      Does child and adolescent mental health in-service training result in equivalent knowledge gain among cadres of non-specialist health workers in Uganda? A pre-test post-test study

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          Abstract

          Background

          Early identification and management of child and adolescent mental health (CAMH) disorders helps to avert mental illness in adulthood but a CAMH treatment gap exists in Uganda. CAMH integration into primary health care (PHC) through in-service training of non-specialist health workers (NSHW) using the World Health Organisation (WHO) Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) is a strategy to address this gap. However, results of such training are not supported by information on training development or delivery; and are undifferentiated by NSHW cadre. We aim to describe an in-service CAMH training for NSHW in Uganda and assess cadre-differentiated learning outcomes.

          Methods

          Thirty-six clinical officers, nurses and midwives from 18 randomly selected PHC clinics in eastern Uganda were trained for 5 days on CAMH screening and referral using a curriculum based on the mhGAP-IG version 1.0 and PowerPoint slides from the International Association of Child and Adolescent Psychiatry and Allied Professions (IACAPAP). The residential training was evaluated through pre- and post- training tests of CAMH knowledge and attitudes using the participants’ post-test scores; and the difference between pre-test and post-test scores. Two-tailed t-tests assessed differences in mean pre-test and post-test scores between the cadres; hierarchical linear regression tested the association between cadre and post test scores; and logistic regression evaluated the relationship between cadre and knowledge gain at three pre-determined cut off points.

          Results

          Thirty-three participants completed both pre-and post-tests. Improved mean scores from pre- to post-test were observed for both clinical officers (20% change) and nurse/midwives (18% change). Clinical officers had significantly higher mean test scores than nurses and midwives (p < 0.05) but cadre was not significantly associated with improvement in CAMH knowledge at the 10% (AOR 0.08; 95 CI [0.01, 1.19]; p = 0.066), 15% (AOR 0.16; 95% CI [0.01, 2.21]; p = 0.170), or 25% (AOR 0.13; 95% CI [0.01, 1.74]; p = 0.122) levels.

          Conclusion

          We aimed to examine CAMH learning outcomes by NSHW cadre. NSHW cadre does not influence knowledge gain from in-service CAMH training. Thus, an option for integrating CAMH into PHC in Uganda using the mhGAP-IG and IACAPAP PowerPoint slides is to proceed without cadre differentiation.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13033-017-0158-y) contains supplementary material, which is available to authorized users.

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          Most cited references32

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          The world health report 2001 - Mental health: new understanding, new hope

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            Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries

            Background Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.
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              Effective in-service training design and delivery: evidence from an integrative literature review

              Background In-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE. Methods A literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education. Results The evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries. Conclusions Educational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.
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                Author and article information

                Contributors
                angela_akol@yahoo.com , angela.akol@uib.no
                joycenalugya@yahoo.com
                rnsylvia@yahoo.com
                jnbabirye@musph.ac.ug
                Ingunn.Engebretsen@uib.no
                Journal
                Int J Ment Health Syst
                Int J Ment Health Syst
                International Journal of Mental Health Systems
                BioMed Central (London )
                1752-4458
                24 August 2017
                24 August 2017
                2017
                : 11
                : 50
                Affiliations
                [1 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, The Global Mental Health Research Group, Center for International Health, , University of Bergen, ; Postboks 7804, N-5009 Bergen, Norway
                [2 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, , Makerere University School of Public Health, ; Kampala, Uganda
                [3 ]ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Department of Psychiatry, , Makerere University College of Health Sciences, ; Kampala, Uganda
                [4 ]Butabika National Mental Health Referral Hospital, Kampala, Uganda
                Author information
                http://orcid.org/0000-0003-4594-3478
                Article
                158
                10.1186/s13033-017-0158-y
                5571627
                034f501c-c4d4-415b-8875-71ccb9ed01b0
                © The Author(s) 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 21 April 2017
                : 20 August 2017
                Funding
                Funded by: Norwegian Research Council ’SeeTheChild – Mental Child Health in Uganda’
                Award ID: RCN #220887
                Award Recipient :
                Funded by: Lanekassen, the Norwegian state loan fund.
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

                Neurology
                child,adolescent,mental health,training,non-specialist health worker,cadre,primary care
                Neurology
                child, adolescent, mental health, training, non-specialist health worker, cadre, primary care

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