Correlates of Performance of Healthcare Workers in Emergency, Triage, Assessment and Treatment plus Admission Care (ETAT+) Course in Rwanda: Context Matters

PLoS One. 2016 Mar 31;11(3):e0152882. doi: 10.1371/journal.pone.0152882. eCollection 2016.


Background: The Emergency, Triage, Assessment and Treatment plus Admission care (ETAT+) course, a comprehensive advanced pediatric life support course, was introduced in Rwanda in 2010 to facilitate the achievement of the fourth Millennium Development Goal. The impact of the course on improving healthcare workers (HCWs) knowledge and practical skills related to providing emergency care to severely ill newborns and children in Rwanda has not been studied.

Objective: To evaluate the impact of the ETAT+ course on HCWs knowledge and practical skills, and to identify factors associated with greater improvement in knowledge and skills.

Methods: We used a one group, pre-post test study using data collected during ETAT+ course implementation from 2010 to 2013. The paired t-test was used to assess the effect of ETAT+ course on knowledge improvement in participating HCWs. Mixed effects linear and logistic regression models were fitted to explore factors associated with HCWs performance in ETAT+ course knowledge and practical skills assessments, while accounting for clustering of HCWs in hospitals.

Results: 374 HCWs were included in the analysis. On average, knowledge scores improved by 22.8/100 (95% confidence interval (CI) 20.5, 25.1). In adjusted models, bilingual (French & English) participants had a greater improvement in knowledge 7.3 (95% CI 4.3, 10.2) and higher odds of passing the practical skills assessment (adjusted odds ratio (aOR) = 2.60; 95% CI 1.25, 5.40) than those who were solely proficient in French. Participants who attended a course outside of their health facility had higher odds of passing the skills assessment (aOR = 2.11; 95% CI 1.01, 4.44) than those who attended one within their health facility.

Conclusions: The current study shows a positive impact of ETAT+ course on improving participants' knowledge and skills related to managing emergency pediatric and neonatal care conditions. The findings regarding key factors influencing ETAT+ course outcomes demonstrate the importance of considering key contextual factors (e.g., language barriers) that might affect HCWs performance in this type of continuous medical education.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Education, Medical, Continuing*
  • Emergency Medical Services
  • Female
  • Health Personnel / education*
  • Humans
  • Male
  • Models, Theoretical*
  • Patient Admission*
  • Rwanda

Grants and funding

DFC received a grant (Maternal Newborn and Child Health in Rwanda, S-065358) from Foreign Affairs and International Trade Canada ( that supported the ETAT+ course in Rwanda as well as CH to undertake a graduate training in Canada. The ETAT+ course received further funding from other institutions/agencies including: International Health Partnership Funding Scheme (, Belgian Development Agency (, and IntraHealth Rwanda ( The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.