Multifaceted intervention to improve health worker adherence to Integrated

Management of Childhood Illness (IMCI) guidelines in Benin*

* Published in American Journal of Public Health 2009;99:837–846.

ICIUM_P6a_presentation_v3.pptx

Alexander K. Rowe, Faustin Onikpo, Marcel Lama, Dawn M. Osterholt,

Samantha Y. Rowe, Michael S. Deming

Background and objective

• WHO’s IMCI strategy aims to improve child health in developing countries by encouraging use of evidence-based guidelines for treating major causes of death

• Studies show that training health workers (HWs) on IMCI guidelines can improve quality of care at outpatient health facilities (HFs)

• However, these studies also revealed substantial room for improvement in adherence to guidelines—even after IMCI training

• Objective: Evaluate an intervention to support HWs after IMCI training in Benin

Methods• Setting: 130 public and licensed private outpatient HFs

• Design: Randomized trial in 16 districts− Two similar areas, 8 districts each; one area randomly

selected as intervention area− HWs in both areas received IMCI training− HWs in intervention area also received package of post-

IMCI-training supports (next slide)− HWs in control area received “usual” supports

(i.e., whatever government provided) − Baseline: In 1999, assessed health care quality before

IMCI training with HF survey (observed consultations, re-examined patients, and interviewed caretakers & HWs)

− Eleven-day IMCI courses took place from 2001–2004− Follow-up HF surveys in 2001, 2002, and 2004

Methods

• Study population: Ill children <5 years at HFs and HWs

• Outcome measures: 1) Children with a potentially life-threatening illness (PLTI) with

recommended treatment (exactly according to IMCI)

2) Children with PLTI with recommended or adequate treatment (not exactly according to IMCI, but still considered life-saving)

3) For all children, an index of overall guideline adherence (% of all IMCI-recommended tasks that were performed)

• Package of post-training supports for IMCI-trained HWs1) Job aids: IMCI patient register and counseling guide

2) Supervision of HWs and supervisors

3) Nonfinancial incentives: Framed certificate of merit presented at a ceremony

Analysis

• Effect size = absolute %-point difference of differences: Effect size = (%POST – %PRE)intervention – (%POST – %PRE)control

• Intention-to-treat analysis: Regression models with time, study area, and time x area interaction terms

• Per protocol analysis:− Needed because IMCI training occurred slowly, and poor

quality care delivered by non-IMCI-trained HWs diluted performance in both study arms

− HWs divided into three groups: 1) HWs with IMCI training + study supports

2) HWs with IMCI training + usual supports

3) HWs without IMCI training

− All F/U surveys (2001–2004) pooled, as results were similar− Model: time, HW group, and time x group interaction terms

Effect

Results: Enrollment & intention-to-treat analysis

• We observed 1244 ill child consultations; 1101 of these were for PLTIs

• In F/U period (2001–2004), although we expected all children to be seen by IMCI-trained HWs, only half were− Partly because IMCI training occurred slowly− Partly because IMCI-trained HWs were not always

scheduled to work during peak hours

• Intention-to-treat analysis: All outcomes improved over time; however, differences in improvements between intervention and control areas were close to zero and not statistically significant (next slide)

Intention-to-treat analysis

0

20

40

60

80

100

Intervention area

40%

35%22%

16%

25%

32%Control area

1999 2001 2004

Year of survey

Per

cent

of

child

ren

rece

ivin

g re

com

men

ded

care

Baseline (pre-IMCI)

Follow-up

0

20

40

60

80

100

IMCI + “usual” supports

Not IMCI trained

IMCI + study supports

1999 2001 2002 2004

Per

cent

of c

hild

ren

rece

ivin

g re

com

men

ded

care

Baseline (pre-IMCI)

Follow-up

Per protocol analysis: Outcome 1 (recommended tx)

Graph shows performance trends for 3 HW groups. Trends for the other 2 outcomes were very similar.

0

20

40

60

80

100

IMCI + “usual” supports

Not IMCI trained

IMCI + study supports

1999 2001 2002 2004

Per

cent

of c

hild

ren

rece

ivin

g re

com

men

ded

care

Baseline (pre-IMCI)

Follow-up

Per protocol analysis: Outcome 1 (recommended tx)

For all outcomes, HWs without IMCI performed poorly, and quality did not change over time.

0

20

40

60

80

100

IMCI + “usual” supports

Not IMCI trained

IMCI + study supports

1999 2001 2002 2004

Per

cent

of c

hild

ren

rece

ivin

g re

com

men

ded

care

Baseline (pre-IMCI)

Follow-up

Per protocol analysis: Outcome 1 (recommended tx)

For all outcomes, IMCI-trained HWs with usual supports out-performed HWs without IMCI training by 19–35 %-points (p<0.05).

0

20

40

60

80

100

IMCI + “usual” supports

Not IMCI trained

IMCI + study supports

1999 2001 2002 2004

Per

cent

of c

hild

ren

rece

ivin

g re

com

men

ded

care

Baseline (pre-IMCI)

Follow-up

Per protocol analysis: Outcome 1 (recommended tx)

IMCI-trained HWs with study supports outperformed IMCI-trained HWs with usual supports by 15–27 %-points; statistically significant for 2 of 3 outcomes.

Potential limitations

• Study design changed from pre-post study with randomized controls (intention-to-treat) to pre-post study with non-randomized controls (per protocol analysis)

• As it is highly unlikely that child’s caretaker would know if HWs received study or usual supports, the change in design was probably not an important source of bias

• Other potential limitations

Bias introduced by observing consultations

Some prescriptions were incomplete

It is difficult to know if “usual” supports in our study reflect usual supports elsewhere

Conclusions

• Training, such as IMCI training, can be useful for implementing clinical guidelines; but it is not enough

• Relatively inexpensive post-training supports, such as those in our study, can lead to additional improvements

• However, even with our study supports, there was considerable room for improvement

• Wherever IMCI is implemented, program managers should ensure that IMCI-trained health workers perform consultations

Thank you!

Merci !