***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE . The goal was to evaluate , through an American Academy of Pediatrics demonstration project , the effectiveness of a curriculum and train-the-trainer model in changing child care providers ' behaviors regarding safe infant sleep practice s. METHODS . Participating licensed child care centers and family child care homes were assigned r and omly to intervention and control groups . Observers performed an initial unannounced visit to each site , to watch infants being placed for sleep , to inventory sleep policies , and to administer question naires to center staff members . Trainers then used the American Academy of Pediatrics curriculum in educational sessions at intervention sites . Three months later , observers conducted a follow-up observation at each site , and staff members completed a question naire about logistic barriers encountered in implementation of safe sleep recommendations . RESULTS . A total of 264 programs and 1212 providers completed the study ; the care of 1993 infants was observed . Provider awareness of the American Academy of Pediatrics infant supine sleep position recommendation increased from 59.7 % ( both groups ) to 64.8 % ( control ) and 80.5 % ( intervention ) . Exclusive use of the supine position in programs increased from 65.0 % to 70.4 % ( control ) and 87.8 % ( intervention ) . Observed supine placement increased from 51.0 % to 57.1 % ( control ) and 62.1 % ( intervention ) . CONCLUSIONS . A sudden infant death syndrome risk reduction curriculum using a train-the-trainer model is effective in improving the knowledge and practice s of child care providers . Perceived parental objections , provider skepticism about the benefits of supine positioning , and lack of program policies and training opportunities are important barriers to implementation of safe sleep policies . Continued education of parents , exp and ed training efforts , and statewide regulations , m and ates , and monitoring are critical to ongoing efforts to decrease further the risk of sudden infant death syndrome in child care AIMS The effectiveness of expert-led ( EX ) and train-the-trainer ( TT ) strategies was compared to a self- study approach ( SS ) for teaching  clinicians motivational interviewing ( MI ) . DESIGN Twelve community treatment programs were assigned r and omly to the three conditions . EX and TT conditions used skill-building workshops and three monthly supervision sessions guided by treatment integrity ratings , performance feedback and coaching techniques . Trainers in TT were first trained and certified in MI and then prepared carefully to deliver the workshops and supervise MI at their programs . Clinicians in SS only received the training material s. SETTING Licensed out-patient and residential addiction and mental health treatment programs in the US state of Connecticut were involved in the study . PARTICIPANTS Ninety-two clinicians who provided addiction treatment within these programs and had limited experience with MI participated in the study . MEASUREMENTS Primary outcomes were the clinicians ' MI adherence and competence and the percentage of clinicians meeting clinical trial st and ards of MI performance . Assessment s occurred at baseline , post-workshop , post-supervision and at 12-week follow-up . FINDINGS The study found EX and TT , in comparison to SS , improved clinicians ' adherence and competence significantly , with higher percentages of clinicians reaching clinical trial st and ards of MI performance and few differences between EX and TT . CONCLUSIONS This study supports the combined use of workshops and supervision to teach community program clinicians MI and suggests the train-the-trainer approach may be a feasible and effective strategy for disseminating empirically supported treatments Objective To develop and test a distance-learning programme to improve the quality and efficiency of family planning services in Guatemala . Methods The setting was rural family planning services in Guatemala . The study design was quasi-experimental with one intervention and one control group and with pre- and post-intervention measures . Two staff members from each of 20 r and omly selected health districts were trained as leaders of the training programme . In turn , the 40 trainers trained a total of 240 service providers , under the supervision of four health area facilitators . The results were compared with 20 r and omly selected control health districts . The intervention was a distance-learning programme including 40 in-class hours followed by 120 inservice practice hours spread over a 4-month period . Distinctively , the programme used a cascade approach to training , intensive supervision , and close monitoring and evaluation . Patient flow analysis was used to determine number of contacts , waiting times , and the interaction time between service providers and clients . Consultation observations were used to assess the quality and completeness of reproductive health information and services received by clients . Results The intervention showed a positive impact on reducing the number of contacts before the consultation and client waiting times . More complete services and better quality services were provided at intervention clinics . Some , but not all , of the study objectives were attained . The long-term impact of the intervention is as yet unknown . Conclusion Distance-learning programmes are an effective methodology for training health professionals in rural areas OBJECTIVE : The National Cancer Institute ( NCI ) developed a manual to guide primary care practice s in structuring their office environment and routine visits so as to enhance nutrition screening , advice/referral , and follow-up for cancer prevention . The adoption of the manual ’s recommendations by primary care practice s was evaluated by examining two strategies : physician training on how to implement the manual ’s recommendations versus simple mailing of the manual . This article reports on the results of a r and omized controlled trial to evaluate the effectiveness of these two strategies . DESIGN : A three-arm , r and omized , controlled study . SETTING : Free-st and ing primary care physician practice s in Pennsylvania and New Jersey . INTERVENTION : Each study practice was r and omly assigned to one of three groups . The training group practice s were invited to send one member from their practice of their choosing to a 3-hour “ train-a-trainer ” workshop , the manual-only-group practice s were mailed the nutrition manual , and the control group practice s received no intervention . For training group practice s , training was provided in the four major components of the nutrition manual : how to organize the office environment to support cancer prevention nutrition-related activities ; how to screen patient adherence to the NCI dietary guidelines ; how to provide dietary advice/referral ; and how to implement a patient follow-up system to support patients in making changes in their nutrition-related behaviors . MEASUREMENTS : The primary outcomes of the study were derived from two evaluation instruments . The observation instrument documented the tools and procedures recommended by the nutrition manual and adopted in patient charts and the office environment . The in-person structured interview evaluated the physician and staff ’s self-reported nutrition-related activities reflecting the nutrition manual ’s recommendations . Data from these two instruments were used to construct four adherence scores corresponding to the areas : office organization , nutrition screening , nutrition advice/referral , and patient follow-up . MAIN RESULTS : The adoption of the manual ’s recommendations was highest among the practice s in the training group as reflected by their higher adherence scores . They organized their office ( P=.005 ) and screened their patients regarding their eating habits ( P=.046 ) significantly more closely to the recommendations of the nutrition manual than practice s in the manual-only group . However , despite being the highest in compliance , the training group practice s were only 54.9 % adherent to the manual ’s recommendations regarding nutrition advice/referral , and 28.5 % adherent to its recommendations on office organization , 23.5 % adherent to its recommendations on nutrition screening , and 14.6 % adherent to its patient follow-up recommendations . CONCLUSIONS : Primary care practice s exposed to the nutrition manual in a training session adopted more of the manual ’s recommendations . Specifically , practice s invited to training were more likely to perform nutrition screening and to structure their office environment to be conducive to providing nutrition-related services for cancer prevention . The impact of the training was moderate and not statistically significant for nutrition advice/referral or patient follow-up , which are important in achieving long-term dietary changes in patients . The overall low adherence scores to nutrition-related activities demonstrates that there is plenty of room for improvement among the practice s in the training group OBJECTIVE : The goal was to determine the effect of training in newborn care and resuscitation on 7-day ( early ) neonatal mortality rates for very low birth weight ( VLBW ) infants . The study was design ed to test the hypothesis that these training programs would reduce neonatal mortality rates for VLBW infants . METHODS : Local instructors trained birth attendants from 96 rural communities in 6 developing countries in protocol and data collection , the World Health Organization Essential Newborn Care ( ENC ) course , and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program ( NRP ) , by using a train-the-trainer model . To test the impact of ENC training , data on infants of 500 to 1499 g were collected by using a before/after , active baseline , controlled study design . A cluster-r and omized , controlled trial design was used to test the impact of the NRP . RESULTS : A total of 1096 VLBW ( 500–1499 g ) infants were enrolled , and 98.5 % of live-born infants were monitored to 7 days . All-cause , 7-day neonatal mortality , stillbirth , and perinatal mortality rates were not affected by ENC or NRP training . CONCLUSIONS : Neither ENC nor NRP training of birth attendants decreased 7-day neonatal , stillbirth , or perinatal mortality rates for VLBW infants born at home or at first-level facilities . Encouragement of delivery in a facility where a higher level of care is available may be preferable when delivery of a VLBW infant is expected Objective : To evaluate whether computer-based learning ( CBL ) improves newly acquired knowledge and is an effective strategy for teaching prenatal ultrasound diagnostic skills to third-year medical students when compared with instruction by traditional paper-based methods ( PBM ) . Study Design : We conducted a r and omized , prospect i ve study involving volunteer junior ( 3rd year ) medical students consecutively rotating through the Obstetrics and Gynecology clerkship during six months of the 2005–2006 academic year . The students were r and omly assigned to permuted blocks and divided into two groups . Half of the participants received instruction in prenatal ultrasound diagnostics using an interactive CBL program ; the other half received instruction using equivalent material by the traditional PBM . Outcomes were evaluated by comparing changes in pre-tutorial and post instruction examination scores . Results : All 36 potential participants ( 100 % ) completed the study curriculum . Students were divided equally between the CBL ( n = 18 ) and PBM ( n = 18 ) groups . Pre-tutorial exam scores ( mean±s.d . ) were 44%±11.1 % for the CBL group and 44%±10.8 % for the PBL cohort , indicating no statistically significant differences ( p>0.05 ) between the two groups . After instruction , post-tutorial exam scores ( mean±s.d . ) were increased from the pre-tutorial scores , 74%±11 % and 67%±12 % , for students in the CBL and the PBM groups , respectively . The improvement in post-tutorial exam scores from the pre-test scores was considered significant ( p<0.05 ) . When post-test scores for the tutorial groups were compared , the CBL subjects achieved a score that was , on average , 7 percentage points higher than their PBM counterparts , a statistically significant difference ( p < 0.05 ) . Conclusion : Instruction by either CBL or PBM strategies is associated with improvements in newly acquired knowledge as reflected by increased post-tutorial examination scores . Students that received CBL had significantlyhigher post-tutorial exam scores than those in the PBM group , indicating that CBL is an effective instruction strategy in this setting BACKGROUND AND OBJECTIVES When attempting to implement evidence -based medicine , such as through clinical guidelines , we often rely on passive educational tactics , for example didactic lectures and bulletins . These methods involve the recipient in relatively superficial processing of information , and any consequent attitude changes can be expected to be short-lived . However , active methods , such as practice -based discussion , should involve recipients in deep processing , with more enduring attitude changes . In this experiment , the aim was to assess the efficacy of an active strategy at promoting deep processing and its effectiveness , relative to a typical passive method , at changing attitudes between groups of GPs over 12 months across an English Health District . METHODS All 191 GPs operating from 69 practice s in the Wirral Health District of Northwest Engl and were assigned , with minimization of known confounding variables , to three experimental groups : active , passive and control . The groups were shown to have similar learning styles . The objective of the study was to impart knowledge of best management of infections as captured in a series of locally developed clinical guidelines . The passive group GPs were given a copy of the guidelines and were invited to an hour-long lecture event . The GPs in the deep group were given a copy of the guidelines and were invited to engage in an hour-long discussion about the guideline content at their own premises . The control group received neither the guidelines nor any educational contact regarding them . Three months before and 12 months after the interventions , all GPs were sent a postal question naire on their preferred empirical antibiotic for 10 common bacterial infections . The responses were compared in order to ascertain whether increased knowledge of best clinical practice was evident in each group . RESULTS Seventy-five per cent ( 144/191 ) of GPs responded to the pre-intervention question naire , 62 % ( 119/191 ) post-intervention . Thirty-four per cent ( 22/64 ) of GPs in the passive group attended the lecture ; 91 % ( 60/66 ) of the active group engaged in discussion at meetings with the authors . A significantly higher proportion of the active group participants ' speaking time , during a sample of four visits , was devoted to verbal indicators of active processing than the passive group lecture attenders ( difference = 55 % , 
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DISCUSSION There is evidence that using a blended learning approach to deliver TTT programs -- combining different techniques such as interactive , multifaceted methods and accompanying learning material s -- can help to effectively disseminate and implement guidelines and curricula to health and social care professionals .