1. 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

2. 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

3. 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

4. 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 HWs 1)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

5. 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

6. 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)

7. Intention-to-treat analysis 1999 2001 2004 Year of survey Percent of children receiving recommended care Baseline (pre-IMCI) Follow-up

8. 1999 2001 2002 2004 Percent of children receiving recommended 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.

9. 1999 2001 2002 2004 Percent of children receiving recommended 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.

10. 1999 2001 2002 2004 Percent of children receiving recommended 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).

11. 1999 2001 2002 2004 Percent of children receiving recommended 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.

12. 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

13. 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

14. Thank you! Merci !