A multifaceted intervention to improve health worker adherence to integrated management of childhood illness guidelines in Benin

Abstract

Objectives: We evaluated an intervention to support health workers after training in Integrated Management of Childhood Illness (IMCI), a strategy that can improve outcomes for children in developing countries by encouraging workers' use of evidence-based guidelines for managing the leading causes of child mortality.

Methods: We conducted a randomized trial in Benin. We administered a survey in 1999 to assess health care quality before IMCI training. Health workers then received training plus either study supports (job aids, nonfinancial incentives, and supervision of workers and supervisors) or usual supports. Follow-up surveys conducted in 2001 to 2004 assessed recommended treatment, recommended or adequate treatment, and an index of overall guideline adherence.

Results: We analyzed 1244 consultations. Performance improved in both intervention and control groups, with no significant differences between groups. However, training proceeded slowly, and low-quality care from health workers without IMCI training diluted intervention effects. Per-protocol analyses revealed that workers with IMCI training plus study supports provided better care than did those with training plus usual supports (27.3 percentage-point difference for recommended treatment; P < .05), and both groups outperformed untrained workers.

Conclusions: IMCI training was useful but insufficient. Relatively inexpensive supports can lead to additional improvements.

FIGURE 1

Timeline of Integrated Management of Childhood Illness (IMCI) training and the study to evaluate posttraining supports: Benin, 1999–2004. ^aZones 1 and 2 were randomized as a group to be the intervention area; zones 3 and 4 were randomized as a group to be the control area. Zone 1 was the trial intervention area in which IMCI was piloted: training began in 2001, and IMCI-trained health workers received study supports. Zone 2 was the trial intervention area in which IMCI began later: training began in 2003, and IMCI-trained health workers received study supports. Zone 3 was the trial control area in which IMCI was piloted: training began in 2001, and IMCI-trained health workers received usual supports. Zone 4 was the trial control area in which IMCI began later: training began in 2003, and IMCI-trained health workers received usual supports.

FIGURE 2

Intention-to-treat analysis of the effect of posttraining supports for health workers trained to use Integrated Management of Childhood Illness (IMCI) guidelines on (a) the percentage of children receiving recommended care, (b) the percentage of children receiving recommended or adequate care, and (c) the mean percentage of needed tasks performed per child: Benin, 1999–2004. Note. 1999 was the baseline period (pre-IMCI); 2001–2004 was the follow-up period.

FIGURE 3

Per-protocol analysis of the effect of training on Integrated Management of Childhood Illness (IMCI) guidelines and posttraining supports, by exposure to interventions on (a) the percentage of children receiving recommended care, (b) the percentage of children receiving recommended or adequate care, and (c) the mean percentage of needed tasks performed per child: Benin, 1999–2004. Note. 1999 was the baseline period (pre-IMCI); 2001–2004 was the follow-up period. ^aAll outcomes were adjusted for case complexity. ^bResults for the IMCI group receiving study supports were significantly greater than those for the IMCI group receiving usual supports only for the comparison of 1999 versus 2004. Results for the IMCI group receiving usual supports were significantly greater than were those for the group without IMCI training only for the comparison of 1999 versus 2001. Results for the IMCI group receiving study supports were significantly greater than those for the group without IMCI training for all years. ^cResults for the IMCI group receiving study supports were never significantly greater than those for the IMCI group receiving usual supports. Results for the IMCI group receiving usual supports were significantly greater than those for the group without IMCI training for the comparisons of 1999 versus 2001 and of 1999 versus 2004. Results for the IMCI group receiving study supports were significantly greater than those for the group without IMCI training for all years. ^dResults for the IMCI group receiving study supports were significantly greater than those for the IMCI group receiving usual supports for the comparisons of 1999 versus 2002 and of 1999 versus 2004. Results for the IMCI group receiving usual supports were significantly greater than those for the group without IMCI training for all years. Results for the IMCI group receiving study supports were significantly greater than those for the group without IMCI training for all years.