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Improved knowledge and reported practice regarding sexually transmitted infections among healthcare providers in rural Vietnam: a cluster randomised controlled educational intervention

  • Pham Thi Lan1, 2Email author,
  • Ho Dang Phuc3,
  • Nguyen Quynh Hoa2, 4,
  • Nguyen Thi Kim Chuc1 and
  • Cecilia Stålsby Lundborg2
BMC Infectious Diseases201414:646

https://doi.org/10.1186/s12879-014-0646-5

Received: 19 February 2014

Accepted: 20 November 2014

Published: 4 December 2014

Abstract

Background

Healthcare providers (HCPs) play a critical role in controlling the spread of sexually transmitted infections (STI) through early and accurate diagnosis, appropriate treatment and prevention counselling. This study aimed to assess the effectiveness of an educational intervention about STI on knowledge and reported practice among HCPs and to explore which determinants may influence the intervention’s effects.

Methods

A cluster randomized controlled educational intervention was carried out in a rural district, Vietnam. 32 communes of the district were randomized into two arms, with 160 HCPs in an STI intervention arm and 144 in a control arm. The STI intervention comprised interactive training with basic STI knowledge, case scenarios, and poster distribution. Questionnaires to evaluate knowledge and reported practice were completed three times: before, during and after the intervention. Correct answer was scored as 1; “do not know”, incorrect answer was scored as 0. Univariate and multilevel multivariate analyses were applied.

Results

Of the maximum 56 points, the mean knowledge score increased significantly in the STI intervention arm and in the control arm post-intervention (37.2 to 48.4, and 32.7 to 41.7, respectively). In multivariate regression analysis, knowledge improvement in the intervention arm was significantly higher than that in the control arm (regression coefficient = 2.97, p = 0.008). Other factors which positively influenced the increase in knowledge were being between 35 and 50 years old, having intermediate professional training, being a pharmacist or working at a village level (regression coefficient: 2.81, 4.43, 5.53 and 7.91, respectively). Post-intervention, the mean reported practice score increased significantly in the STI intervention arm (from 17.6 to 21.8) and insignificantly in the control arm (maximum 36 points). Factors which positively influenced the increase in reported practice were being between 35 and 50 years old, having intermediate professional training, or working at a pharmacy/drugstore (regression coefficient: 2.15, 3.33 and 3.22, respectively).

Conclusions

This study indicates that an educational intervention including interactive training and multi-faceted interventions may be effective in improving STI knowledge and reported practice of HCPs at grassroots level, particularly among pharmacists, HCPs who work in villages or pharmacies/drugstores, and who initially have low STI knowledge.

Keywords

STI Healthcare provider Intervention Knowledge Reported practice Vietnam

Background

Sexually transmitted infections (STI) have a negative impact on the health, economy and quality-of-life of individuals, as well as whole communities. The World Health Organization estimates that there are 499 million new cases of the four most common curable STI (trichomonasis, chlamydial infection, gonorrhea and syphilis) each year worldwide [1]. Furthermore, millions of viral STI cases also occur annually, and are attributable mainly to the human immunodeficiency virus (HIV), herpes, human papilloma virus and hepatitis B [2]. Improved case management of STI has been scientifically proven to reduce the incidence of HIV infection in the general population [3],[4]. In low-income countries, STI management is usually inadequate [5]-[7] and STI control programmes often fail for various reasons [8]. It has been shown that healthcare providers (HCPs) play an important role in reducing the burden of STI through effective prevention and management [9]. In addition, studies have shown positive impact of continuing medical education or educational interventions on improvement of HCPs’ knowledge and/or practices [10],[11], STI management [12],[13] and patient outcomes [14].

In Vietnam, curable STI are common among high-risk groups [15],[16] and not uncommon in the general population [17]. Misconceptions and low knowledge on STI among people in the community [18],[19] and HCPs [20], delays in women living in rural areas from seeking care for STI [21], and negative attitudes among HCPs towards STI patients [18], have been shown. Furthermore, previous studies demonstrate that people with STI may seek healthcare from different sources [18] and that HCPs at different levels have very low knowledge and inadequate practice regarding STI, and rarely participate in STI training [20]. Data on the effects of educational interventions regarding STI are limited. The present study was a continuation of the other studies conducted in the same setting [18]-[20]. The aims of this study were to evaluate whether this type of intervention could improve HCPs’ knowledge and reported practice regarding STI in rural Vietnam, and to examine which determinants may possibly impact the intervention’s effectiveness. The ultimate goal was to promote good STI care at grassroots level.

Methods

Study setting and participants

This study was a part of a cluster randomised controlled educational intervention conducted in Bavi district, Hanoi, Vietnam in 2010 and 2011. Bavi is a rural district, 60 km west of Hanoi. It covers 410 km2 and has a population of approximately 235,000 people within 32 communes. The healthcare system in Bavi district includes one district hospital with 150 beds, three regional polyclinics, 32 commune health centres, village health workers, private facilities and pharmacies/drugstores.

The study participants included medical personnel (medical doctors, assistant medical doctors, nurses and midwives) and pharmacy personnel (pharmacists and drugstore workers) working in public and private facilities in the 32 communes of Bavi district, Hanoi.

Intervention

A cluster randomised, controlled trial, with randomisation at commune level, was conducted to examine the effect of a multi-faceted educational intervention on knowledge and reported practice regarding STI and acute respiratory infections (ARI) among HCPs. The 32 communes of Bavi district were randomized into two arms (16 communes per arm), an STI intervention arm and an ARI intervention arm. All HCPs working in the communes were invited to participate. Each arm got active intervention for one topic and functioned as control arm for the other topic (Figure 1). Changes in STI knowledge and reported practice among HCPs from before to after the intervention were assessed through a self-completed questionnaire.
Figure 1

Flow chart of the study.

In the STI intervention arm, three activities were performed sequentially from September 2010 to March 2011, including: (i) training session on STI knowledge, (ii) training session on STI case scenario management of four syndromes (see below) based on national guidelines, and (iii) poster distribution to all healthcare facilities in the communes included. In each training session, 25–30 HCPs participated and were divided into four small groups (approximately 5–7 HCPs per group) to discuss different issues related to STI assisted by a trainer (PTL) and facilitator (HDP). Afterwards, each small group presented their group work results, which were then discussed with the entire group. Finally, the trainer gave correct information and a lecture on the topics discussed. For the first training, the issues discussed focussed on STI knowledge, i.e. diseases considered as STI, suspected symptoms, routes of transmission, causes and risk factors, complications, and partner treatment and notification. In the second training, the trainer briefly mentioned the contents of the first training and then divided the HCPs into four small groups to discuss case scenarios of four common STI syndromes including vaginal discharge, urethral discharge, genital ulcers and lower abdominal pain syndromes. The sessions were evaluated using evaluation forms.

Intervention messages used for this study were developed and reviewed by a group of researchers based on the national guidelines. Intervention activities were piloted in two districts outside the study setting. A poster was designed and reviewed by the authors. It comprised short specific messages focusing on STI causes, risk behaviours and complications.

Questionnaire

The questionnaire included an STI part and an ARI part with the same questions for two arms. However, for the STI intervention arm, the STI part was presented just after questions on HCPs’ characteristics and for the ARI arm, an alternative version of the questionnaire was constructed with the ARI section first, followed by the STI part.

The STI section of the questionnaire was a modified version of questionnaire from a previous study in the same setting [20]. It mainly contained closed and a few open-ended questions on STI knowledge (such as identification of the diseases, suspected symptoms, routes of transmission, causes and risk factors, complications, and partner treatment and notification) and four case scenarios one each for the four syndromes mentioned above.

Data collection and ethics

The questionnaire was distributed to HCPs just before the first and second training sessions, and one month after poster distribution. The questionnaire was self-completed under the supervision of the research team. No discussion or aid was allowed. All respondents were assured that they could respond anonymously, and that the results would only be used for research purposes. Verbal consent was sought from the respondents before distribution of the questionnaire. The study was approved by the Hanoi Medical University, Vietnam.

Data entry and analyses

ACCESS software was used for data entry, and SPSS version 16 and STATA version 11 for analyses. Proportions, mean, median, minimum and maximum were used for the descriptive analyses. Overall STI knowledge and reported practice was evaluated by scoring. Every correct answer was scored as 1. “Do not know”, incorrect answers or missing responses were given a score of 0. The maximum score one could obtain in the knowledge and reported practice sections of the questionnaire were 56 and 36, respectively. Knowledge and practice improvements were defined by differences of scores after and before the intervention.

Chi-square test was performed to examine the differences between proportions. Cochran test was used for several relative binary samples to verify the proportion trend of correct answers before, during, and after the intervention. Wilcoxon test was used for univariate comparisons of providers’ knowledge and reported practice before and after the intervention. Mann–Whitney test was used to compare knowledge and practice improvements between the STI intervention and control arm. Moreover, multi-level regression analysis was applied to determine which factors influenced the improvements. Intra-cluster correlation (ICC) was used to evaluate the similarity of HCPs within communes regarding STI knowledge and/or practice improvement. Regression coefficients and p-values in T- test, Cochran, Wilcoxon, and Mann–Whitney tests were adjusted for ICC [22].

Results

Of 415 eligible HCPs, 304 participated in the study, including 160 in the STI intervention arm and 144 in the control arm. The respondents’ mean age was 41.1 years (range 22–69). Most HCPs (89%) had 2–3 years or 6–12 months professional education, and 63% worked at commune health centres. In general, there were no significant differences in socio-demographic characteristics between the HCPs in the STI intervention arm and control arm (p > 0.05). The respondents’ characteristics are shown in Table 1.
Table 1

Socio-demographic characteristics of 304 healthcare providers in the STI intervention arm and control arm

Category

Intervention arm

Control arm

Total

p-value

% (n = 160)

% (n = 144)

% (n = 304)

 

Age (years)

    

<35

34

33

34

0.943

35–50

39

41

40

>50

26

26

26

Sex

    

Male

35

33

34

0.664

Female

65

67

66

Occupation

   

MD/AMDa

59

51

55

0.479

Pharmacistb

24

29

27

Nurse/midwife

16

20

18

Working places

    

Commune health centre

68

57

63

0.084

Village level

8

18

12

Private clinic

5

6

6

Pharmacy/drugstore

19

19

19

Professional education

    

Lower professional training (6–12 months)

12

22

16

0.073

Intermediate professional training (2–3 yrs)

77

67

72

University/post-graduate

11

11

11

aMD: Medical doctor (15 respondents); AMD: assistant medical doctor (70 respondents).

bUniversity pharmacist (2 respondents), intermediate-training pharmacist 3(50 respondents), and low-training pharmacist (27 respondents).

Intervention and STI knowledge

In general, for almost all questions on STI knowledge, the proportion of correct answers increased significantly in both arms, although HCPs from the STI intervention arm showed a greater increase than their colleagues in the control arm. Gonorrhoea and syphilis were classified as STI by more than 90% of respondents in the two arms both before and after the intervention (Table 2). Less than two thirds of the HCPs in both arms classified trichomonas, genital warts and chlamydia as STI pre-intervention; post-intervention this increased significantly. Compared to before the intervention, the percentage of respondents who classified pubic lice as an STI post-intervention increased significantly in both the STI intervention and the control arm (from 26% to 79% and from 15% to 40%, respectively; p < 0.05). Before the intervention, 70% and 54% of HCPs in the intervention arm classified candidiasis and bacterial vaginosis (BV) as STI, and these were 58% and 37%, in the control arm respectively. After the intervention, a significant improvement to what was observed for candidiasis but not BV in the intervention arm. Conversely, in the control arm, more HCPs classified candidiasis and BV as STI (71% and 59% respectively; p < 0.05) (data not shown).
Table 2

Responses to the questions on STI knowledge among 304 healthcare providers of the two arms before (B), during (D) and after (A) the intervention

Correct identification

STI intervention arm

Control arm

% (n = 160)

% (n = 144)

 

B

D

A

p *

B

D

A

p *

STI identification

        
 

Gonorrhoea

94

98

99

0.119

93

98

99

0.040

 

Syphilis

93

96

97

0.312

92

94

99

0.033

 

Trichomonas

55

70

89

0.000

51

58

69

0.007

 

Genital warts

66

83

93

0.000

63

66

80

0.005

 

Chlamydia

40

55

77

0.000

36

49

50

0.019

Suspected symptoms

        
 

Vaginal discharge

70

91

96

0.000

60

72

81

0.001

 

Urethral discharge

75

92

98

0.000

72

78

90

0.001

 

Genital ulcers, warts

91

95

99

0.027

83

90

92

0.158

 

Lower abdominal pain in females

52

65

84

0.000

35

53

62

0.000

Causes of STI

        
 

Bacteria

69

79

75

0.226

60

77

84

0.000

 

Viruses

76

74

85

0.106

65

72

88

0.000

 

Parasites/protozoa

43

60

77

0.000

43

53

56

0.088

Risk factors for STI

        
 

Unsafe sex

91

93

100

0.005

87

91

97

0.010

 

Unsafe blood transfusion

40

61

75

0.000

29

38

51

0.000

Routes of transmission

        
 

Sexual intercourse

97

93

99

0.106

97

100

100

0.121

 

Blood transfusion/ needle sharing

51

71

81

0.000

44

58

60

0.016

 

Mother-to-child

64

83

93

0.000

56

56

76

0.000

Necessity of partner examination/treatment

        
 

Gonorrhoea

96

97

99

0.310

95

97

100

0.047

 

Syphilis

96

96

99

0.284

93

96

99

0.028

 

Trichomonas

62

77

86

0.000

63

63

65

0.887

 

Genital warts

82

86

96

0.017

77

69

76

0.231

 

Chlamydia

50

64

78

0.000

47

46

54

0.292

Complications of STI if untreated

        
 

Infertility

96

95

99

0.333

88

95

94

0.052

 

Ectopic pregnancy/cervical cancer

81

92

93

0.022

65

85

87

0.000

 

Adverse pregnancy outcome

85

92

98

0.004

71

90

95

0.000

 

Pelvic inflammation

52

65

79

0.000

36

50

49

0.017

Ways of STI prevention

        
 

Save sex including condom use

98

99

98

0.822

94

98

100

0.009

 

Being faithful**

93

96

97

0.186

81

90

97

0.000

* Cochran test for verifying the proportion trend of correct answers before, during and after the intervention, with p-value adjusted for ICC.

** Maintaining sexual loyalty to one's spouse or lover.

Concerning knowledge about partner notification for patients who suffered from trichomonas, genital warts or chlamydia, Table 2 shows significant improvements among HCPs in the intervention arm but not the control arm. Furthermore, pre-intervention, 71% and 81% of the HCPs in the STI intervention arm answered the necessity of partner notification and treatment for BV and candidiasis, and these were significantly reduced post-intervention (57% and 69%). In contrast, no significant differences knowledge on partner treatment for these two infections were observed in the control arm (data not shown).

Regarding risk factors, there was a decreased number of HCPs in the intervention arm who answered that a risk factor for STI was bad hygiene (62% before, 45% after; p < 0.05), while the number of providers who answered that having sex during menstruation posed a risk was almost unchanged (55% before, 58% after; p > 0.05). In contrast, more HCPs in the control arm responded that bad hygiene (66% before, 69% after; p > 0.05), or having sex during menstruation (37% before, 56% after; p < 0.05) were risk factors (data not shown).

Table 3 shows the improvement of STI knowledge in the two arms. Overall, after the intervention, the mean knowledge scores of most of the HCPs in both arms increased significantly (p < 0.05) and HCPs in the STI intervention arm presented higher mean knowledge scores than their colleagues in the control arm. The total mean knowledge score of the respondents in the STI intervention arm pre-intervention was 37.2 (range 12–53; median 38), and 48.4 post-intervention (range 19–56; median 50); for the control group it was 32.7 (range 0–53; median 33) and 41.7 (range 13–56; median 44), respectively. The improvement observed in both arms was statistically significant (p < 0.05). The proportion of HCPs that had positive knowledge improvement was 91% in the STI intervention arm and 80% in the control arm (p = 0.004). The ICCs of knowledge improvement among HCPs within communes were 0.21 in the STI intervention arm and 0.16 in the control arm.
Table 3

Univariate comparison of knowledge improvement between the STI intervention arm and control arm

 

STI intervention arm

Control arm

 

Mean score (n = 160)

Mean score (n = 144)

Category

Before

After

p *

Difference

Before

After

p *

Difference

p **

Sex

         
 

Male

37.4

48.7

0.000

11.3

33.0

41.1

0.000

8.0

0.261

 

Female

37.2

48.2

0.000

11.1

32.51

42.0

0.000

9.5

0.212

Age (years)

         
 

<35

37.4

48.5

0.000

11.0

34.0

42.1

0.000

8.1

0.223

 

35-50

35.6

48.5

0.000

12.9

34.0

43.3

0.000

9.4

0.107

 

>50

39.5

48.2

0.000

8.7

29.1

38.7

0.000

9.6

0.694

Profesional education

         
 

Lower training (6–12 months)

32.5

43.8

0.002

11.3

23.7

36.0

0.000

12.3

0.897

 

Intermediate training (2–3 yrs)

37.3

48.8

0.000

11.5

34.9

43.8

0.000

8.8

0.029

 

University/post-graduate

41.8

50.3

0.001

8.6

36.4

40.3

0.044

3.9

0.261

Occupation

         
 

MD/AMDa

38.8

48.5

0.000

9.7

37.4

43.6

0.000

6.2

0.034

 

Pharmacist

37.4

48.0

0.000

10.6

28.0

37.7

0.000

9.7

0.638

 

Nurse/midwife

33.3

48.3

0.000

15.0

30.7

42.6

0.000

11.9

0.317

Working places

         
 

Commune health centre

38.9

48.7

0.000

9.8

37.0

44.1

0.000

7.2

0.082

 

Village level

29.6

46.2

0.001

16.5

21.7

38.0

0.000

16.3

0.987

 

Private clinic

41.4

51.1

0.012

9.8

21.8

27.6

0.091

5.9

0.154

 

Pharmacy/drugstore

33.5

47.9

0.000

14.4

32.0

41.7

0.000

9.7

0.154

Total scores

         
 

Mean

37.2

48.4

0.000

11.2

32.7

41.7

0.000

9.0

0.207

 

Median

38

50

0.000

11

33

44

0.000

8

0.142

 

Minimum

12

19

 

−14

0

13

 

−10

 
 

Maximum

53

56

 

40

53

56

 

46

 

* Wilcoxon test (T-test for mean of total scores) to compare related samples (before and after intervention) of each arm, with p-value adjusted for ICC.

** Mann–Whitney test (T-test for mean of total scores) to compare knowledge scores differences (after - before) between the intervention and the control arms, with p-value adjusted for ICC.

aMD: Medical doctor AMD: assistant medical doctor.

When comparing by HCPs’ characteristics between the STI intervention and control arms, a significantly higher improvement in knowledge scores was observed in the STI intervention arm among HCPs who had intermediate professional training, and medical doctors or assistant medical doctors (p < 0.05).

Intervention and STI reported practice

In general, after the intervention, the reported practice scores of most of HCPs in both arms increased significantly (p < 0.05) and HCPs in the STI intervention arm presented higher scores than their colleagues in the control arm. Average reported practice score of the respondents in the STI intervention arm before the intervention was 17.6 (range 1–28, median 18), and after the intervention 21.8 (range 0–34; median 23); for the control arm it was 14.8 (range 1–26; median 16) and 18.5 (range 3–33; median 19), respectively. The improvement observed in both arms was statistically significant (p < 0.05). The difference in average scores before and after the intervention (after - before) in the STI intervention arm and control arm was 4.3 and 3.6, respectively, but this difference was not statistically significant (p > 0.05). The proportion of HCPs that had positive practice improvement was 72% in the STI intervention arm and 65% in the control arm (p = 0.349). The ICCs of practice improvement among HCPs within communes were for 0.20 in the STI intervention arm and 0.07 in the control arm.

When comparing the differences in the mean scores after and before the intervention between the two arms by each category of participants (Table 4), the results showed significantly higher improvement in the STI intervention arm, only among HCPs with intermediate professional training.
Table 4

Univariate comparison of practice improvement between the STI intervention arm and control arm

 

STI intervention arm

Control arm

 

Mean score (n = 160)

Mean score (n = 144)

Category

Before

After

p *

Difference

Before

After

p *

Difference

p **

Sex

         
 

Male

18.9

21.9

0.003

2.9

14.6

18.4

0.000

3.8

0. 857

 

Female

16.8

21.8

0.001

5.0

14.9

18.5

0.000

3.6

0.228

Age (years)

         
 

<35

16.9

22.0

0.001

5.2

14.8

18.5

0.002

3.6

0.442

 

35-50

16.9

22.4

0.000

5.5

16.3

19.8

0.001

3.4

0.052

 

>50

19.4

20.7

0.149

1.3

12.5

16.5

0.004

4.0

0.291

Education

         
 

Lower training (6–12 months)

16.0

16.2

0.892

0.2

13.5

16.6

0.002

3.2

0.358

 

Intermediate training (2–3 yrs)

17.5

22.6

0.000

5.2

15.3

19.1

0.000

3.8

0.047

 

University/post-graduate

19.6

22.2

0.159

2.6

14.6

18.3

0.008

3.8

0.767

Occupation

         
 

MD/AMDa

18.2

22.3

0.000

4.1

15.7

19.6

0.000

3.9

0.494

 

Nurse/midwife

17.8

21.1

0.079

3.3

13.8

17.0

0.018

3.3

0.936

 

Pharmacist

15.7

21.1

0.014

5.3

14.4

18.1

0.000

3.7

0.279

Working places

         
 

Commune health centre

18.2

22.2

0.001

4.0

16.0

19.6

0.001

3.6

0.386

 

Village level

18.1

18.7

0.503

0.6

13.6

17.6

0.002

3.9

0.184

 

Private clinic

18.0

22.0

0.024

4.0

11.3

13.0

0.445

1.8

0.173

 

Pharmacy/drugstore

14.8

21.7

0.002

6.8

13.6

18.2

0.001

4.6

0.173

Total scores

         
 

Mean

17.6

21.8

0.000

4.3

14.8

18.5

0.000

3.6

0.581

 

Median

18

23

0.000

4

16

19

0.000

3

0.388

 

Minimum

1

0

 

−21

1

3

 

−12

 
 

Maximum

28

34

 

29

26

33

 

22

 

* Wilcoxon test (T-test for mean of total scores) to compare related samples (before and after intervention) of each arm, with p-value adjusted for ICC.

** Mann–Whitney test (T-test for mean of total scores) to compare practice scores differences (after - before) between the STI intervention and the control arm, with p-value adjusted for ICC.

aMD: Medical doctor; AMD: assistant medical doctor.

Factors influencing the interventions’ effects

Table 5 presents the improvement of HCPs’ STI knowledge and reported practice using multi-level multivariate regression analysis. The improvement of both STI knowledge and reported practice was not significant in reference categories (regression constants were 0.78 and −0.99; p > 0.05). However, being aged between 35 and 50 years, having intermediate professional training, being a pharmacist, working at village level, or being part of the STI intervention arm, were significant determinants which added 2.81, 4.43, 5.53, 7.91, or 2.97 points, respectively (p < 0.05) to the improvement of HCPs’ STI knowledge.
Table 5

Knowledge and practice improvement in multi-level multivariate regression analysis

 

Knowledge improvement

Practice improvement

Regression coefficient *

p-value

Regression coefficient *

p-value

Participation in the STI intervention

    

No

0

Reference

0

Reference

Yes

2.97

0.008

0.33

0.688

Age (years)

    

<35

0.35

0.795

2.00

0.075

35-50

2.81

0.028

2.15

0.042

>50

0

Reference

0

Reference

Professional education

    

Lower training (6–12 months)

0

Reference

0

Reference

Intermediate training (2–3 yrs)

4.43

0.006

3.33

0.014

University/Postgraduate

1.72

0.424

2.26

0.207

Occupation

    

MD/AMDa

0

Reference

0

Reference

Nurse/midwife

1.60

0.263

−0.36

0.756

Pharmacist

5.53

0.001

−0.73

0.580

Working places

    

Commune health centrer

0

Reference

0

Reference

Village level

7.91

0.000

1.65

0.299

Private clinic

2.22

0.347

0.96

0.620

Pharmacy/drugstore

0.73

0.671

3.22

0.024

Constant

0.78

0.718

−0.99

0.573

*Regression coefficients were adjusted for intra-cluster correlations.

aMD: Medical doctor; AMD: assistant medical doctor.

Concerning HCPs’ reported practice, being aged between 35 and 50 years, having intermediate professional training, or working at a pharmacy/drugstore, were significant determinants which added 2.15, 3.33, or 3.22 points (p < 0.05).

Discussion

In this study we found that HCPs who received an educational intervention on STI were more likely to have improved STI knowledge and reported practice than those in the control arm, though a significant different in reported practice was not found in multivariate analysis. The study also identified several determinants influencing the interventions’ effectiveness.

Our results showed that the number of correct answers increased after each educational activity, both in the intervention as well as the control arm, and that the majority of the improvements were statistically significant. This improvement could be due to the impact of the intervention because HCPs in the intervention arm showed a greater increase than their colleagues in the control arm. Moreover, for issues where we considered initial knowledge low, such as STI identification and partner treatment for pubic lice, genital herpes/warts, and chlamydia, improved much more among HCPs in STI intervention arm as compared to that of the control arm. On the other hand, misconceptions on the definition of STI and partner treatment for BV and candidiasis, and risk factors of STI, decreased among HCPs in the STI intervention arm, and increased in the control arm.

Surprisingly, more than 60% of the HCPs in both arms considered partner treatment necessary for BV and candidiasis, and also, more than half believed that bad hygiene or sex during menses were risk factors for STI. After the intervention, the misconceptions were reduced but remained common. Previous studies conducted in the same setting, also show these misconceptions among HCPs [20], as well as among people in the community [18],[19]. After several years, these misconceptions have remained mostly unchanged, though HCPs’ knowledge in the present study was better as compared to the earlier study [20]. This implies the need to provide educational activities that focus not only on knowledge, but also misconceptions.

The ICCs in the STI intervention arm can be considered high, which indicates high similarities of the HCPs within communes regarding the improvements of both knowledge and practice. This may be due to discussions on STI among trained HCPs within communes after each educational activity. Lower values of ICCs in the control arm might indicate less emphasising STI discussions among HCPs within communes, especially issues related to written case scenarios (reported practice).

We considered that the intervention activities might provide impacts on knowledge and practice improvement. The impacts could be produced by: i) training/education activities, ii) repeated filling of the questionnaires, and iii) possible discussions among HCPs on the related topic. Multi-level multivariate regression analysis showed significant impact of several factors, including being part of the STI intervention, age, professional education, occupation or working place, on knowledge improvement. Among these factors, being part of the STI intervention contributed 3 points to knowledge improvement.

Randomised controlled studies have shown positive effects of educational interventions on improving HCPs’ practice [23] or self-efficacy to perform a certain task [24],[25] especially when taking multi-component interventions into account, including a simulated client method [26],[27]. Our study did not show significant direct impacts of the STI intervention on HCPs’ reported practice, as shown elsewhere [28]. However, our study did show that, indirect impacts of the intervention on practice improvement were significant in specific groups based on, age, professional education, and working place.

Notably, in the multivariate analysis models, our results showed significant knowledge improvement among pharmacists and reported practice, among those who worked at pharmacies/drugstores. Studies have also shown that educational interventions improve pharmacy workers’ practice [26],[29], syndromic management of STI at pharmacies [30], and cost-effectiveness of syndromic management of STI though pharmacist training [31]. Studies in Vietnam and elsewhere show that STI patients usually go to pharmacies/drugstores for treatment or advice [18],[32]-[34] because of the lower costs, higher accessibility [18],[34] and less stigmatisation [18]. Moreover, the majority of pharmacies treat STI patients [35] therefore training of pharmacy workers can improve antimicrobial prescribing practices for STI syndrome management in Vietnam [36]. Thus improving knowledge and practice for pharmacists/drug sellers may play an important role in STI control and prevention strategies, and it cannot be ignored.

Methodological considerations

A consensus about the types of situations in which the contamination of educational interventions is more or less likely has been shown [37], and cluster randomisation may reduce contamination [38]. However, in our study, prevention of contamination could not be entirely assured due to the fact that HCPs in different communes could meet each other on various occasions where they might have exchanged information, including issues related to STI. Therefore, the improvement in the control group could partially have been a consequence of contamination. Subsequently, the impact of the STI intervention might actually be higher than presented in our results. Further, reported practice of HCPs might not reflect their actual practice due to lack of information provided in the scenarios, which might cause biases in the evaluation of practice improvement.

A point which might be raised here is that, asking questions repetitively can automatically result in improvements. Possibly, completing the questionnaire three times made the HCPs familiar with the questions asked, which made their responses easier the subsequent times. It could also be assumed that filling in the questionnaire several times is an intervention in itself. Moreover, possible discussions about STI among HCPs in both arms after each training session could be a potential influencing factor.

The randomised design can be considered the best protection against confounding and selection bias [39]. By choosing a randomised controlled design, the intention of producing comparable groups of HCPs who differ only in terms of their exposure to intervention during the study was assured, and several potential confounders or biases, such as geographical location, HCPs’ professional education and occupation, could be removed. However, due to the fact that the study was carried out in a rural district of Vietnam, the results of this study may be considered to be representative for only HCPs working at similar grassroots healthcare settings.

We found that the initial proportions of correct answers and mean knowledge scores in the intervention arm were higher as compared to those in the control arm. This could be due to the difference in the order of questions related to STI and ARI within the questionnaires used for each arm. Moreover, HCPs may have placed more attention on the topic they were trained in. Consequently, they could have correctly answered more questions related to the main topic of the arm in which they participated. However, the above mentioned effects did not influence our results since the improvements were calculated as the differences between pre- and post- intervention scores.

We also analysed the impact of each educational activity on STI knowledge and reported practice and found that, the differences of STI knowledge before and after the first training, as well as the second training, were not significant (results not shown). However, knowledge improvement in the whole intervention process was significant. While, practice training was given only once in our study, which might possibly have influenced the impact of the STI intervention on practice improvement. Hence, multi-faceted interventions have been shown to be effective in particular environments [26],[36]. We used an interactive training method for each training session, which is not commonly applied in our educational system, as well as training in the field. This method is considered to motivate active learning from participants and provide better training effects, and can result in moderately large changes in practice, while didactic lectures alone are unlikely to affect change [40].

Conclusion

This study shows the effectiveness of an educational intervention on STI knowledge of HCPs at grassroots level, especially for pharmacists, HCPs who worked in villages, and who initially had low STI knowledge. Our study does not show the significant effect of intervention on practice overall, however the significant effect was observed among pharmacy/drugstore workers. Interactive training and multi-faceted educational interventions may give better and more sustainable improvements, and the education curriculum should not only focus on providing correct knowledge but also address misconceptions.

Declarations

Acknowledgements

The authors wish to thank all the healthcare providers from the 32 communes of Bavi district for their participation. Special thanks to Dr Nguyen Phuong Hoa (lecturer at Hanoi Medical University) and FilaBavi’s staff for their assistance during the study period. The study was funded by ASIA Link, Swedish Research Council, Sweden. Ho Dang Phuc (co-author) was partially funded by Nafosted, Vietnam.

Authors’ Affiliations

(1)
Hanoi Medical University
(2)
Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet
(3)
Institute of Mathematics, VAST
(4)
National Cancer Hospital

References

  1. Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections - 2008. 2012, WHO, GenevaGoogle Scholar
  2. Global Strategy for the Prevention and Control of Sexually Transmitted Infections: 2006–2015. Breaking the Chain of Transmission. 2007, WHO, GenevaGoogle Scholar
  3. Manhart LE, Holmes KK: Randomized controlled trials of individual-level, population-level, and multilevel interventions for preventing sexually transmitted infections: what has worked?. J Infect Dis. 2005, 191: s7-s24. 10.1086/425275.View ArticlePubMedGoogle Scholar
  4. Grosskurth H, Todd J, Mwijarubi E, Mayaud P, Nicoll A, Ka-Gina G, Newell J, Mayaud P, Nicoll A, Newell J, Mabey D, Hayes R, Mosha F, Senkoro K, Changalucha J, Klokke A, Mwijarubi E, Mugeye K: Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet. 1995, 346: 530-536. 10.1016/S0140-6736(95)91380-7.View ArticlePubMedGoogle Scholar
  5. Khandwalla HE, Luby S, Rahman S: Knowledge, attitudes, and practices regarding sexually transmitted infections among general practitioners and medical specialists in Karachi, Pakistan. Sex Transm Infect. 2000, 76: 383-385. 10.1136/sti.76.5.383.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Voeten HA, Otido JM, O'Hara HB, Kuperus AG, Borsboom GJ, Ndinya-Achola JO, Bwayo JJ, Habbema JD: Quality of sexually transmitted disease case management in Nairobi, Kenya: a comparison among different types of healthcare facilities. Sex Transm Dis. 2001, 28: 633-642. 10.1097/00007435-200111000-00005.View ArticlePubMedGoogle Scholar
  7. Sihavong A, Lundborg CS, Syhakhang L, Vernby A, Panyanouvong A, Marions L, Wahlström R: Health providers' competence in the management of reproductive tract infections in Vientiane, Lao People's Democratic Republic. Int J STD AIDS. 2007, 18: 774-781. 10.1258/095646207782212270.View ArticlePubMedGoogle Scholar
  8. Mayaud P, Mabey D: Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sex Transm Infect. 2004, 80: 174-182. 10.1136/sti.2002.004101.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Sexually Transmitted and Other Reproductive Tract Infections: A Guide to Essential Practice. 2005, WHO, GenevaGoogle Scholar
  10. Davis DA, Thomson MA, Oxman AD, Haynes RB: Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992, 268: 1111-1117. 10.1001/jama.1992.03490090053014.View ArticlePubMedGoogle Scholar
  11. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD: Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009, ᅟ:ᅟ.,Google Scholar
  12. Green M, Hoffman IF, Brathwaite A, Wedderburn M, Figueroa P, Behets F, Dallabetta G, Hoyo C, Cohen MS: Improving sexually transmitted disease management in the private sector: the Jamaica experience. AIDS. 1998, 12: s67-s72. 10.1097/00002030-199815000-00009.View ArticlePubMedGoogle Scholar
  13. Harrison A, Karim SA, Floyd K, Lombard C, Lurie M, Ntuli N, Wilkinson D: Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: randomized controlled trial. AIDS. 2000, 14: 2769-2779. 10.1097/00002030-200012010-00017.View ArticlePubMedGoogle Scholar
  14. García PJ, Holmes KK, Cárcamo CP, Garnett GP, Hughes JP, Campos PE, Whittington WL: Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial. Lancet. 2012, 379: 1120-1128. 10.1016/S0140-6736(11)61846-1.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Nguyen VT, Nguyen TL, Nguyen DH, Le TT, Vo TT, Cao TB, O'Farrell N: Sexually transmitted infections in female sex workers in five border provinces of Vietnam. Sex Transm Dis. 2005, 32: 550-556. 10.1097/01.olq.0000175415.06716.6d.View ArticlePubMedGoogle Scholar
  16. Go VF, Frangakis C, Le Nam V, Bergenstrom A, Sripaipan T, Zenilman JM, Celentano DD, Quan VM: High HIV sexual risk behaviors and sexually transmitted disease prevalence among injection drug users in Northern Vietnam: implications for a generalized HIV epidemic. J Acquir Immune Defic Syndr. 2006, 42: 108-115. 10.1097/01.qai.0000199354.88607.2f.View ArticlePubMedGoogle Scholar
  17. Lan PT, Lundborg CS, Phuc HD, Sihavong A, Unemo M, Chuc NT, Khang TH, Mogren I: Reproductive tract infections including sexually transmitted infections: a population-based study of women of reproductive age in a rural district of Vietnam. Sex Transm Infect. 2008, 84: 126-132. 10.1136/sti.2007.027821.View ArticlePubMedGoogle Scholar
  18. Lan PT, Faxelid E, Chuc NT, Mogren I, Lundborg CS: Perceptions and attitudes in relation to reproductive tract infections including sexually transmitted infections in rural Vietnam: a qualitative study. Health Policy. 2008, 86: 308-317. 10.1016/j.healthpol.2007.11.007.View ArticlePubMedGoogle Scholar
  19. Lan PT, Mogren I, Phuc HD, Lundborg CS: Lack of knowledge about sexually transmitted infections among women in rural Vietnam. BMC Infect Dis. 2009, 9: 85-10.1186/1471-2334-9-85.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Lan PT, Stålsby Lundborg C, Mogren I, Phuc HD, Chuc NTK: Knowledge and practice among healthcare providers in rural Vietnam regarding sexually transmitted infections. Sex Transm Dis. 2009, 36: 452-458. 10.1097/OLQ.0b013e31819fe9ae.View ArticlePubMedGoogle Scholar
  21. Thi Thu H, Ziersch A, Hart G: Healthcare-seeking behaviours for sexually transmitted infections among women attending the national institute of dermatology and venereology in Vietnam. Sex Transm Infect. 2007, 83: 406-410. 10.1136/sti.2006.022079.View ArticlePubMedGoogle Scholar
  22. Goldstein H: Multilevel Statistical Models. 1999, Institute of Education, LondonGoogle Scholar
  23. Verhoeven V, Avonts D, Vermeire E, Debaene L, Van Royen P: A short educational intervention on communication skills improves the quality of screening for Chlamydia in GPs in Belgium: a cluster randomised controlled trial. Patient Educ Couns. 2005, 57: 10-10.1016/j.pec.2004.05.001.View ArticleGoogle Scholar
  24. Ammentorp J, Sabroe S, Kofoed PE, Mainz J: The effect of training in communication skills on medical doctors' and nurses' self-efficacy. A randomized controlled trial. Patient Educ Couns. 2007, 66: 270-277. 10.1016/j.pec.2006.12.012.View ArticlePubMedGoogle Scholar
  25. Doyle D, Copeland HL, Bush D, Stein L, Thompson S: A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance. Patient Educ Couns. 2011, 82: 100-109. 10.1016/j.pec.2010.02.013.View ArticlePubMedGoogle Scholar
  26. Chuc NT, Larsson M, Do NT, Diwan V, Tomson G, Falkenberg T: Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. J Clin Epidemiol. 2002, 55: 1148-1155. 10.1016/S0895-4356(02)00458-4.View ArticlePubMedGoogle Scholar
  27. Chalker J, Ratanawijitrasin S, Chuc NT, Petzold M, Tomson G: Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand - a randomized controlled trial. Soc Sci Med. 2005, 60: 131-141. 10.1016/j.socscimed.2004.04.019.View ArticlePubMedGoogle Scholar
  28. Canchihuaman FA, Garcia PJ, Gloyd SS, Holmes KK: An interactive internet-based continuing education course on sexually transmitted diseases for physicians and midwives in Peru. PLoS One. 2011, 6: e19318-10.1371/journal.pone.0019318.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Garcia P, Hughes J, Carcamo C, Holmes KK: Training pharmacy workers in recognition, management, and prevention of STDs: district-randomized controlled trial. Bull World Health Organ. 2003, 81: 806-814.PubMedGoogle Scholar
  30. García PJ, Carcamo CP, Garnett GP, Campos PE, Holmes KK: Improved STD syndrome management by a network of clinicians and pharmacy workers in Peru: the PREVEN network. PLoS One. 2012, 7: e47750-10.1371/journal.pone.0047750.View ArticlePubMedPubMed CentralGoogle Scholar
  31. Adams EJ, Garcia PJ, Garnett GP, Edmunds WJ, Holmes KK: The cost-effectiveness of syndromic management in pharmacies in Lima, Peru. Sex Transm Dis. 2003, 30: 379-387. 10.1097/00007435-200305000-00002.View ArticlePubMedGoogle Scholar
  32. Sihavong A, Lundborg CS, Syhakhang L, Akkhavong K, Tomson G, Wahlström R: Antimicrobial self medication for reproductive tract infections in two provinces in Lao People's Democratic Republic. Sex Transm Infect. 2006, 82: 182-186. 10.1136/sti.2005.016352.View ArticlePubMedPubMed CentralGoogle Scholar
  33. Ngo AD, Ratliff EA, McCurdy SA, Ross MW, Markham C, Pham HT: Health-seeking behaviour for sexually transmitted infections and HIV testing among female sex workers in Vietnam. AIDS Care. 2007, 19: 878-887. 10.1080/09540120601163078.View ArticlePubMedGoogle Scholar
  34. Garcıa PJ, Carcamo CP, Chiappe M, Holmes KK: Sexually transmitted and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru. Sex Transm Infect. 2007, 83: 142-146. 10.1136/sti.2006.022657.View ArticlePubMedGoogle Scholar
  35. Chalker J, Chuc NT, Falkenberg T, Do NT, Tomson G: STD management by private pharmacies in Hanoi: practice and knowledge of drug sellers. Sex Transm Infect. 2000, 76: 299-302. 10.1136/sti.76.4.299.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Chalker J, Chuc NTK, Falkenberg T, Tomson G: Private pharmacies in Hanoi, Vietnam: a randomized trial of a 2-year multi-component intervention on knowledge and stated practice regarding ARI, STD and antibiotic/steroid requests. Trop Med Int Health. 2002, 7: 803-810. 10.1046/j.1365-3156.2002.00934.x.View ArticlePubMedGoogle Scholar
  37. Keogh-Brown MR, Bachmann MO, Shepstone L, Hewitt C, Howe A, Ramsay CR, Song F, Miles JNV, Torgerson DJ, Miles S, Elbourne D, Harvey I, Campbell MJ: Contamination in trials of educational interventions. Health Technol Assess. 2007, 11: 1-128. 10.3310/hta11430.View ArticleGoogle Scholar
  38. Armstrong R, Waters E: Systematic reviews in health promotion and public health intervention. The Cochran Collaboration 2007, ., [http://ph.cochrane.org/sites/ph.cochrane.org/files/uploads/GuidelinesHP_PHreviews.pdf]
  39. Rotman KJ: Epidemiology. 2002, Oxford University Press, New YorkGoogle Scholar
  40. O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J: Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001, 2: CD003030-doi:10.1002/14651858. CD003030Google Scholar

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© Lan et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. 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.

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