BackgroundThe quality of primary care delivered in resource-limited settings is low. While some progress has been made using educational interventions, it is not yet clear how to sustainably improve care for common acute illnesses in the outpatient setting. Management of urinary tract infection is particularly important in resource-limited settings, where it is commonly diagnosed and associated with high levels of antimicrobial resistance. We describe an educational programme targeting non-physician health care providers and its effects on various clinical quality metrics for urinary tract infection.MethodsWe used a series of educational interventions including 1) formal introduction of a clinical practice guideline, 2) peer-to-peer chart review, and 3) peer-reviewed literature describing local antimicrobial resistance patterns. Interventions were conducted for clinical officers (N = 24) at two outpatient centers near Nairobi, Kenya over a one-year period. The medical records of 474 patients with urinary tract infections were scored on five clinical quality metrics, with the primary outcome being the proportion of cases in which the guideline-recommended antibiotic was prescribed. The results at baseline and following each intervention were compared using chi-squared tests and unpaired two-tailed T-tests for significance. Logistic regression analysis was used to assess for possible confounders.FindingsClinician adherence to the guideline-recommended antibiotic improved significantly during the study period, from 19% at baseline to 68% following all interventions (Χ2 = 150.7, p < 0.001). The secondary outcome of composite quality score also improved significantly from an average of 2.16 to 3.00 on a five-point scale (t = 6.58, p < 0.001). Interventions had different effects at different clinical sites; the primary outcome of appropriate antibiotic prescription was met 83% of the time at Penda Health, and 50% of the time at AICKH, possibly reflecting differences in onboarding and management of clinical officers. Logistic regression analysis showed that intervention stage and clinical site were independent predictors of the primary outcome (p < 0.0001), while all other features, including provider and patient age, were not significant at a conservative threshold of p < 0.05.ConclusionThis study shows that brief educational interventions can dramatically improve the quality of care for routine acute illnesses in the outpatient setting. Measurement of quality metrics allows for further targeting of educational interventions depending on the needs of the providers and the community. Further study is needed to expand routine measurement of quality metrics and to identify the interventions that are most effective in improving quality of care.

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There were no differences between the participants' perceptions of privacy (p¼0.62), embarrassment (p¼0.17), physical discomfort (p=1.0), or pain (p=0.36) between the tampon and clinician-collected methods. However, more women reported feeling "very well cared for" during the clinician-collected method, compared to the tamponcollection (p¼ < 0.01). Most women (n ¼ 261; 80.3%) were willing to collect the tampon at home and bring the specimen with them into the clinic. In our study population, 146 (44.9%) women were familiar with using tampons. About half of the women (182; 56%) reported that carrying the tampon for an hour was "very easy," while 62 (19.1%) reported some difficulty with using the tampon. Interpretation: Slightly more women preferred a clinician-collected swab compared to a self-collected tampon in our study population. While there were no differences in relation to privacy, pain, or discomfort, the clinician-collected method allowed women to feel better cared for, which might have driven the observed difference in preference. Therefore, tampon-collected specimens could be a viable alternative for those patients who do not wish to undergo a pelvic examination or who prefer home-collection as a means for cervical cancer screening. Funding: None.

Short Communication The problem Despite health research capacity growth in low-and middle-income countries (LMICs), the evidence for effective capacity-building strategies is lacking. [1] Most studies describe efforts to strengthen research agendas and design, while authorship and writing competencies are overlooked. However, universities in Africa can play a powerful role in addressing these challenges. Master's theses of postgraduate medical residents in Kenya must be written in English; yet the students come from diverse language backgrounds without formal undergraduate writing instruction. Together with widely adopted courses in research methods, attention has to be given to postgraduate writing skill development to facilitate publication on a competitive global scale.