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Background: Correct treatment of potentially life-threatening illnesses (PLTIs) in children under 5 years, such as malaria, pneumonia, and diarrhea, can substantially reduce mortality. The Integrated Management of Childhood Illness (IMCI) strategy has been shown to improve treatment of child illnesses, but multiple studies have shown that gaps in health worker performance remain after training. To better understand factors related to health worker performance, we analyzed 9,330 patient consultations in Benin from 2001-2002, after training one of the first cohorts of 32 health workers in IMCI., Methods: With data abstracted from patient registers specially designed for IMCI-trained health workers, we examined associations between health facility-, health worker-, and patient-level factors and 10 case-management outcomes for PLTIs., Results: Altogether, 63.6% of children received treatment for all their PLTIs in accordance with IMCI guidelines, and 77.8% received life-saving treatment (i.e., clinically effective treatment, even if not exactly in accordance with IMCI guidelines). Performance of individual health workers varied greatly, from 15-88% of patients treated correctly, on average. Multivariate regression analyses identified several factors that might have influenced case-management quality, many outside a manager's direct control. Younger health workers significantly outperformed older ones, and infants received better care than older children. Children with danger signs, those with more complex illnesses, and those with anemia received worse care. Health worker supervision was associated with improved performance for some outcomes., Conclusions: A variety of factors, some outside the direct control of program managers, can influence health worker practices. An understanding of these influences can help inform the development of strategies to improve performance.

Background: The simulated client (SC) method for evaluating health worker performance utilizes surveyors who pose as patients to make surreptitious observations during consultations. Compared to conspicuous observation (CO) by surveyors, which is commonly done in developing countries, SC data better reflect usual health worker practices. This information is important because CO can cause performance to be better than usual. Despite this advantage of SCs, the method's full potential has not been realized for evaluating performance for pediatric illnesses because real children have not been utilized as SCs. Previous SC studies used scenarios of ill children that were not actually brought to health workers. During a trial that evaluated a quality improvement intervention in Benin (the Integrated Management of Childhood Illness [IMCI] strategy), we conducted an SC survey with adult caretakers as surveyors and real children to evaluate the feasibility of this approach and used the results to assess the validity of CO., Methods: We conducted an SC survey and a CO survey (one right after the other) of health workers in the same 55 health facilities. A detailed description of the SC survey process was produced. Results of the two surveys were compared for 27 performance indicators using logistic regression modeling., Results: SC and CO surveyors observed 54 and 185 consultations, respectively. No serious problems occurred during the SC survey. Performance levels measured by CO were moderately higher than those measured by SCs (median CO - SC difference = 16.4 percentage-points). Survey differences were sometimes much greater for IMCI-trained health workers (median difference = 29.7 percentage-points) than for workers without IMCI training (median difference = 3.1 percentage-points)., Conclusion: SC surveys can be done safely with real children if appropriate precautions are taken. CO can introduce moderately large positive biases, and these biases might be greater for health workers exposed to quality improvement interventions., Trial Number: http://clinicaltrials.gov Identifier NCT00510679.

Objectives: To estimate the impact of the Integrated Management of Childhood Illness (IMCI) strategy on early-childhood mortality, we evaluated a malaria-control project in Benin that implemented IMCI and promoted insecticide-treated nets (ITNs)., Methods: We conducted a before-and-after intervention study that included a nonrandomized comparison group. We used the preceding birth technique to measure early-childhood mortality (risk of dying before age 30 months), and we used health facility surveys and household surveys to measure process indicators., Results: Most process indicators improved in the area covered by the intervention. Notably, because ITNs were also promoted in the comparison area children's ITN use increased by about 20 percentage points in both areas. Regarding early-childhood mortality, the trend from baseline (1999-2001) to follow-up (2002-2004) for the intervention area (13.0% decrease; P < .001) was 14.1% (P < .001) lower than was the trend for the comparison area (1.3% increase; P = .46)., Conclusions: Mortality decreased in the intervention area after IMCI and ITN promotion. ITN use increased similarly in both study areas, so the mortality impact of ITNs in the 2 areas might have canceled each other out. Thus, the mortality reduction could have been primarily attributable to IMCI's effect on health care quality and care-seeking.

Objective: In developing countries, supervision is a widely recognized strategy for improving health worker performance; and anecdotally, maintaining regular, high-quality supervision is difficult. However, remarkably little research has explored in depth why supervision is so challenging., Methods: In the context of a trial to improve health worker adherence to Integrated Management of Childhood Illness (IMCI) guidelines and strengthen supervision in southeastern Benin, we used record reviews, focus group discussions, key informant interviews, and cross-sectional surveys to examine the supervision process., Findings: Initially, little IMCI supervision occurred. The frequency increased substantially after implementing a series of workshops, but then deteriorated. Quantitative and qualitative data revealed obstacles to supervision at multiple levels of the health system. Based on supervisors' opinions, the main problems were: poor coordination; inadequate management skills and ineffective management teams; a lack of motivation; problems related to decentralization; health workers sometimes resisting IMCI implementation; and less priority given to IMCI supervision because of incentives for non-supervision activities, a lack of leadership, and an expectation of integrated supervision. To this list, based on our observations, we add: the increasing supervision workload, time required for non-supervision activities, project interventions not always being implemented as planned, and the loss of particularly effective supervisors. In terms of correctly completing steps of the supervision process, the quality of supervision was generally good., Conclusions: Managers should monitor supervision, understand the evolving influences on supervision, and use their resources and authority to both promote supervision and remove impediments to supervision. Support from leaders can be crucial, thus donors and politicians should help make supervision a true priority. As with front-line clinicians, supervisors are health workers who need support. We emphasize the importance of research to identify effective and affordable strategies for improving supervision frequency and quality. (ClinicalTrials.gov number NCT00510679).

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.

A key goal of the Integrated Management of Childhood Illness (IMCI) strategy is to improve the management of childhood illness at health facilities. IMCIguidelines contain many counselling messages, and as it is not known how well caretakers recall these messages, we studied caretakers' recall of IMCI messages when given under ideal conditions. At a clinic in Benin, a study clinician performed counselling and confirmed caretakers'comprehension of all messages. Caretakers were randomly assigned to be interviewed either immediately after the consultation or a day later. Recall was assessed with general and focused open-ended questions. Recall was assessed for 55 caretakers, 29.1% of whom were literate. Caretakers received 3-75 messages (mean = 38.7). The mean percentage of messages recalled was 89.7% immediately after the consultation and 81.9% one day later. These results support IMCI's recommendation that health workers should verify caretakers' comprehension by asking caretakers to repeat counselling messages during consultations.

Background: In developing countries, health workers often do not follow clinical practice guidelines. However, few studies have examined why different types of errors occur., Methods: We analysed a sample of consultations of children with non-severe malaria (defined as fever without signs of severe illness) from a health facility survey conducted in Ouémé Département, Benin. Treatment was defined as correct (recommended antimalarial), a minor error (non-recommended antimalarial), or a major error (no antimalarial)., Results: In all, 85 health workers and 289 children were studied. In a multivariate logistic regression analysis, the following factors were significantly associated with major errors: treatment by a physician (adjusted odds ratio [aOR] = 13.57, 95% CI: 1.45-126.75), child's age <12 months (aOR = 3.41, 95% CI: 1.15-10.07), and child's temperature (aOR = 0.58 per degrees C, 95% CI: 0.34-0.97). Factors significantly associated with minor errors were: child's temperature (aOR = 1.43 per degrees C, 95% CI: 1.07-1.92), electricity at the health facility (aOR = 3.10, 95% CI: 1.05-9.17), >/=1 supervision visit in the past 6 months (aOR = 0.33, 95% CI: 0.14-0.77), fever treatment wall chart in the consultation room (aOR = 0.29, 95% CI: 0.12-0.73), and number of non-fever chief complaints (aOR = 0.67 per complaint, 95% CI: 0.48-0.93). In-service training in malaria treatment was not significantly associated with either error type., Conclusions: Many factors may influence health worker performance, and factors such as pre-service training may influence performance in unexpected ways. Identifying different errors and analysing them separately can help reveal potential causes that may be masked by combining errors into a single category.

Objectives: To prepare for the implementation of Integrated Management of Childhood Illness (IMCI) in Benin, we studied the management of ill children younger than 5 years at outpatient health facilities., Methods: We observed a representative sample of consultations; after each consultation, we interviewed caregivers and reexamined children. Health workers' performance was evaluated against IMCI guidelines. To identify determinants of performance, statistical modeling was performed and 6 focus groups with health workers were conducted to solicit their opinions., Results: Altogether, 584 children were enrolled and 101 health workers were observed; 130 health workers participated in focus group discussions. Many serious deficiencies were found: incomplete assessment of children's signs and symptoms, incorrect diagnosis and treatment of potentially life-threatening illnesses, inappropriate prescription of dangerous sedatives, missed opportunities to vaccinate, and failure to refer severely ill children for hospitalization. Quantitative and qualitative analyses showed various health facility-, health worker-, caregiver-, and child-related factors as possible determinants of health worker performance., Conclusions: Action is urgently needed. Our results suggest that to improve health care delivery, interventions should target both the health system and the community level.