摘要：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. To reduce the enormous burden of child mortality in developing countries, the World Health Organization (WHO) and other partners developed the Integrated Management of Childhood Illness (IMCI) strategy. 1 IMCI has 3 components: improving case management practices of health workers (especially in outpatient health facilities), strengthening health systems, and promoting community and family health practices. To improve case management practices, IMCI encourages the use of evidence-based guidelines for identifying and treating the leading causes of child deaths (e.g., pneumonia, diarrhea, and malaria 2 ) in first-level health facilities that lack sophisticated diagnostic equipment and treatments. WHO recommends implementing the guidelines through an 11-day in-service training course, a follow-up visit to health workers' facilities in 4 to 6 weeks to reinforce new practices, and job aids (a flipchart and wall chart of clinical algorithms, a pictorial counseling guide, and a 1-page form for recording a patient's assessments, illness classifications, and treatments). For brevity, we describe this implementation process as IMCI training. More than 110 countries are implementing IMCI, and studies have demonstrated that the strategy can improve quality of care at health facilities 3 – 6 and seems to reduce mortality. 7 However, these studies also revealed substantial room for improvement in adherence to IMCI guidelines. For example, IMCI-trained health workers correctly treated only 58% to 73% of children needing an oral antimicrobial. 5 , 6 , 8 , 9 To improve adherence, health workers need support after IMCI training. 9 In 1999, Benin adopted the IMCI strategy and began planning its introduction. Assistance was provided through a US-funded malaria control project, the Africa Integrated Malaria Initiative. During planning, concerns were raised about WHO's implementation approach: the training might not lead to long-term changes in health worker practices, and printing an IMCI recording form for each patient would be unaffordable. Therefore, we designed a package of supports to follow IMCI training and conducted a trial to evaluate them. We characterized the effectiveness and cost of the posttraining supports (primary objective) and IMCI training (secondary objective) on health care quality for all illnesses combined.
