The effect of training in Integrated Management of Childhood Illness (IMCI) on the performance and healthcare quality of pediatric healthcare workers: a systematic review

Efeitos do treinamento na estratégia de Atenção Integrada às Doenças Prevalentes na Infância (AIDPI) sobre o desempenho dos profissionais de saúde na qualidade do atendimento às crianças: uma revisão sistemática

REVISÃO REVIEW

The effect of training in Integrated Management of Childhood Illness (IMCI) on the performance and healthcare quality of pediatric healthcare workers: a systematic review

Efeitos do treinamento na estratégia de Atenção Integrada às Doenças Prevalentes na Infância (AIDPI) sobre o desempenho dos profissionais de saúde na qualidade do atendimento às crianças: uma revisão sistemática

João Joaquim Freitas do Amaral^I; Cesar Gomes Victora^II

^IDepartamento de Saúde Materno Infantil. Faculdade de Medicina. Universidade Federal do Ceará. Rua Prof. Costa Mendes 1608, 2º. Andar, Rodolfo Teófilo, Fortaleza, CE, Brasil. CEP: 60.430-970. E-mail: [e-mail]

^IIDepartamento de Medicina Social. Programa de Pós-Graduação em Epidemiologia. Faculdade de Medicina. Universidade Federal de Pelotas. E-mail: [e-mail]

ABSTRACT

OBJECTIVES: to analyze the effect of training in Integrated Management of Childhood Illness (IMCI) on the quality of case management by healthcare workers based on a systematic review of the literature.

METHODS: the authors searched the databases MEDLINE, LILACS, PAHO and WHOLIS for the search terms Integrated Management of Childhood Illness (IMCI), and analyzed documents published by Pan American Health Organization, World Health Organization and the Brazilian Ministry of Health between January 1993 and July 2006. The quality of the methodology was assessed using the criteria developed by Downs and Black.

RESULTS: thirty-five papers were reviewed. Twelve of these validated the IMCI algorithm and found the sensitivity to be high and the specificity to be over 80% for major illnesses. Twenty-three papers assessed the performance of healthcare workers, eight of these with no control group. The present study shows clear evidence of improvement in the performance of healthcare workers employed at healthcare facilities with IMCI. The main methodological weaknesses of the study were lack of control of confounding factors and lack of information regarding statistical power.

CONCLUSIONS: the performance of healthcare workers tends to improve at public healthcare facilities when IMCI is introduced.

Key words: Integrated Management of Childhood Illness, Child Health Services, Child health

RESUMO

OBJETIVOS: analizar o efeito do treinamento na estratégia de Atenção Integrada às Doenças Pevalentes na Infância (AIDPI) na qualidade do manejo de casos pelos trabalhoadores de saúde, com base em uma revisão sistemática de literatura.

MÉTODOS: foram revisados estudos nas bases de dados MEDLINE, LILACS, PAHO e WHOLIS com as palavras-chave: Atenção Integral às Doenças Prevalentes na Infância (AIDPI); além de documentos da Organização Pan-americana da Saúde, Organização Mundial da Saúde e do Ministério da Saúde do Brasil, de janeiro de 1993 até julho de 2006. A qualidade metodológica dos artigos foi avaliada pelos critérios de Downs e Black.

RESULTADOS: trinta e três artigos foram identificados. Desses, 14 tinha como objetivo validar os algoritmos do AIDPI obtendo altos níveis de sensibilidade e especificidade para as principais doenças. Dez artigos avaliaram o desempenho do trabalhador de saúde sem incluir um grupo externo de comparação, e nove artigos compararam o desempenho de trabalhadores da saúde treinados e não treinados na estratégia. Os estudos mostraram evidência significativa de melhora no desempenho dos trabalhadores de saúde em unidades com AIDPI. Os principais problemas metodológicos encontrados foram a falta de controle de fatores de confusão e a falta de registro do poder estatístico.

CONCLUSÕES: há evidências científicas de melhoria do cuidado às crianças em unidades com profissionais capacitados em AIDPI, o que foi evidenciado particularmente nos estudos realizados com melhor qualidade metodológica.

Palavras-chave: Atenção Integral às Doenças Prevalentes na Infância, Serviços de saúde da criança, Saúde da criança

Introduction

The Integrated Management of Childhood Illness (IMCI) strategy was drawn up by the World Health Organization (WHO) in collaboration with the United Nations Children's Fund (UNICEF) with the aim of improving child health indicators. The global strategy was launched in 1993^1,2 and was introduced in Brazil in 1996, initially in the North and Northeast states where conditions for child health are the least favourable.³

The IMCI strategy includes training of health workers in the management of diseases common in childhood, with emphasis on diarrhea, respiratory infections, malaria, measles and malnutrition. It also includes support for health services that deal with the prevention of specific diseases and health promotion. The IMCI training course originally lasted 11 days, but in a number of countries and locations the course has been reduced to seven or eight days.⁴

Although the IMCI strategy has already been introduced in more than 100 countries,⁵ so far no systematic review of the literature has evaluated whether there has been an improvement in the performance of health workers subsequent to the introduction of this strategy. Such information would be extremely useful for planners and policy-makers in the area of child health. The present review summarises the literature on the quality of case management by health workers trained in IMCI.

Methods

The systematic review of the literature on the IMCI strategy included studies directly or indirectly dealing with the question of whether the training of health workers in IMCI has resulted in an adequate performance in the management of the main health problems arising in childhood.

The publications were located and selected using electronic medical science databases - MEDLINE (National Library of Medicine) and LILACS (Latin American Literature on Medical Science) - in addition to the databases of the international organizations PAHO (Pan American Health Organization) and WHO (World Health Organization), using the following key words: AIDPI (Atenção Integrada às Doenças Prevalentes da Infância), IMCI (Integrated Management of Childhood Illness) and AIEPI (Atención Integrada a las Enfermedades Prevalentes de la Infancia). The review was broadened to include other sources. Thus, officials from health institutions (PAHO, WHO and the Brazilian Ministry of Health) provided references for additional studies on IMCI, and unpublished articles of acceptable quality were included. The search covered the period from January 1993 (when IMCI was launched) to July 2006.

Studies were included if they contained quantitative data comparing the performance of healthcare workers trained in IMCI to that of workers with no such training. Uncontrolled studies on the performance of health workers trained in IMCI were also eligible. Studies measuring the impact of IMCI on health indicators but not the performance of health workers were not included. Also excluded were studies using an exclusively qualitative methodology, manuals, technical information packs and reports providing no evaluation of the strategy.

Analytical experimental or observational designs were included. The outcome parameters included performance indicators of health workers in evaluation, classification, treatment and counseling of mothers.

Subsequently a critical evaluation of the selected articles was carried out, using the 27 quality criteria proposed by Downs and Black, including communication, external validity, internal validity (bias), internal validity (confounding factors) and statistical power.⁶ These criteria relate to positive, partially positive or negative responses to questions on the methodological features of the article, such as whether the statistical tests used to measure the main results were adequate.

The responses to the 27 quality criteria were entered into an Excel spreadsheet. A methodology score was used to indicate the quality of each article with regard to the strength of the evidence by dividing the number of positive items by the number of items evaluated.

Data collection was carried out using an article extraction form requesting the following information: reference, key words, country, aims, outline, sample size, outcome, main results and comments. This last item included a brief analysis of the methodology and the implications of the study in terms of decision-making and future research.

To facilitate the analysis, the articles were divided into: 1) preliminary studies on the IMCI algorithm; 2) studies with no external control group ("before and after" type) and 3) studies with an external control group.

Results

Four hundred and thirty documents in the MEDLINE, LILACS, WHOLIS and PAHO databases contained the key words AIDPI, IMCI or AIEPI. In addition, seven documents published by the WHO and PAHO between January 1993 and July 2006 were included.

Of these documents (manuals, technical information packs, reports and articles) 33 met the inclusion criteria of the study. The studies had all been carried out by researchers working in developing countries (17 in Africa where the strategy was first tested and put into practice).

A list of these 33 articles can be found in Table 1 (preliminary studies evaluating the IMCI algorithm with a view to validation), Table 2 (studies evaluating the performance of healthcare workers trained in IMCI with no external control group) and Table 3 (studies with an external control group evaluating the performance of healthcare workers trained in IMCI).

The principal methodological problems encountered included failure to control for confounding factors in studies with control groups and failure to determine the statistical power of most of the uncontrolled studies. Given the variety of problems detected, the methodology score for the articles varied from 0.50 to 1.00.

Fourteen articles dealt with the validation of specific aspects of the IMCI algorithm, comparing the diagnostic studies carried out by health workers trained in the strategy with the gold standard set by experienced pediatricians. These studies showed levels of sensitivity and specificity above 80% for most illnesses (Table 1).^7-20 The main exception was the low sensitivity of pallor in the palms as an indicator of anemia.^10,16 Two authors reported low specificity for signs indicating the need for hospital referral,^11,18 while another¹⁷ observed a specificity of 74%.

Nine articles evaluated the performance of health workers without reference to an external control group.^21-29 Some cross-sectional studies measured performance after training and reported absolute levels of adequacy,^21,23-26 with, for example, 80% of healthcare workers asking about immunizations. Others compared the performance of the same health workers before and after training.^28,29 Generally, these studies showed high levels of satisfactory performance, with a number of exceptions, including the correct treatment for anemia,^23,24 evaluation of general danger signs,^21,23 evaluation of the health of carers,^26,27 or the need to return immediately to the health unit.^21,23

The study conducted by Kelley et al.²² in Uganda, which also falls into this category, compared the performance of healthcare workers who received training in IMCI plus immediate feedback from other trained workers to the performance of trainees not receiving such feedback, showing that feedback improves performance.

Out of ten articles evaluating the performance of healthcare workers in comparison with an external control group,^30-39 five were of high quality with a methodology score above 0.9,^31-35 the others receiving scores between 0.5 and 0.86. ^30,33,36,37

The studies with an external control group included both studies of efficacy, in which healthcare workers were specially trained by the researchers and subsequently evaluated, and studies of effectiveness, in which previously trained workers were evaluated under routine medical care conditions. All the studies (Table 3) provide significant evidence of improvement in the performance of trained health workers in terms of recognition of general danger signs,³⁴ verification of vaccination status,^32,34 advice on eating habits,31 knowledge of carers regarding children's health,³² performance of health workers at the facility,^32,34,37,38 adequate prescription of antibiotics^34-36,39 and communication with mothers.^33-35

The study in Uganda showed a significant impact on several of the items studied, but differences between trained and untrained healthcare workers were slight.³⁸ This may be attributed to the short duration of the training process and/or the use of poorly qualified instructors in an attempt to achieve as wide a coverage as possible.³⁸

Discussion

The studies reviewed fall basically into three categories: 1) studies for initial validation of the IMCI algorithm, 2) studies without an external control group, evaluating the performance of trained healthcare workers and 3) studies with a control group, comparing trained and untrained healthcare workers.

The first studies carried out were validation studies, as it was necessary to evaluate the discriminatory power of the IMCI algorithm before introducing it into other countries. These studies provided evidence of the ability of IMCI to detect nutritional problems7 and to identify unvaccinated children¹⁷ and seriously ill children in need of referral,^11,15,18 and showed IMCI to be useful in the management of the main childhood health problems^9,13,14,19 with adequate levels of sensitivity and specificity.^8,12 The main exception was the diagnosis of anemia based on palmar pallor which was associated with low to moderate accuracy.^10,16 These preliminary studies were very useful in that they laid the foundations for the strategy and gained respectability for the algorithm in the medical community, which was initially somewhat skeptical of some of the procedures included in the IMCI, such as the diagnosis of pneumonia based on breathing frequency, without the use of radiology or auscultation.

The second category of studies was carried out to evaluate the performance of health workers with or without a control. The uncontrolled studies evaluated the adequacy of the performance,⁴⁰ that is, whether IMCI-trained healthcare workers had high levels of performance for the evaluation, classification and counseling of children and their carers. These studies provided evidence of adequate performance levels among healthcare workers trained in IMCI,⁷ showed that feedback from other trained staff improved performance further,^21,23-26 and that IMCI is important for counseling carers.²⁷ One study suggested that the IMCI improves care for sick children, but only if the health facility has a good infrastructure.²⁹

These findings were confirmed in studies involving an external control group, where the methodology is more sophisticated and allows to determine the likelihood of the observed effect being due to IMCI training.^40,41 These studies provided evidence of improved performance among healthcare workers trained in IMCI,^{30,32,34,37-39} a positive effect of IMCI on nutritional status,³¹ better communication in the group trained in IMCI33 and adequate use of antimicrobial agents.³⁶

There was considerable variation between the studies with regard to study design, outcome parameters, target population and sample size. It was therefore not possible to obtain an overall average using meta-analytical techniques. However, this did not significantly alter the fact that most of the studies showed a positive association between IMCI training and performance, including those studies with a high methodology score. Two of the studies described here^36,37 included overall analyses of investigations carried out for the Multi-Country of IMCI Evaluation, which are tantamount to a meta-analysis.

It is important to point out that many different types of healthcare workers were trained in IMCI. In African countries, most were intermediate-level medical or nursing assistants belonging to various categories with more than 18-36 months training. A recent evaluation showed that training in IMCI improved the performance of healthcare workers at all levels, including qualified physicians.⁴² In Brazil, nurses trained in IMCI had a performance equal to or better than that of doctors trained in IMCI.³⁴

All but six studies were English language publications.^{21,23,24,26,30,31} It is possible that non-native English-speaking authors preferred to publish in that language, as clearly shown in one case.³⁴ It should also be borne in mind that some publishers of English-language periodicals discriminate against work submitted by researchers from under-developed countries.⁴³

One problem to be considered is the bias of the publication, given that there is a greater likelihood of articles being accepted if they present positive rather than negative results.⁴⁴ It should be noted that this review identified three unpublished studies, all presenting positive results.^21,25,30

As for the methodological problems encountered, according to the criteria developed by Downs and Black, failure to describe the statistical power and failure to control for confounding factors were the most common. Although their statistical power was not specified, the studies that evaluated performance used samples of more than 100 children, and, therefore, are sufficiently powerful statistically to detect important differences. It should be pointed out that, among the control studies where adjustments were made for confounding factors, there was evidence of improvement in the performance of healthcare workers at the health facilities using IMCI.^31-36

In conclusion, the studies evaluated show scientific evidence of improvement in child healthcare in facilities with staff trained in IMCI in terms of advice on nutrition, weight gain, knowledge of children's health, correct treatment, evaluation of general danger signs, and correct prescription of antibiotics. More studies are required to clarify whether this is also the case for treatment of diarrhea plus dehydration, detection and treatment of anemia and earache. Localities where IMCI has not yet been introduced, or has been only partially introduced, should be encouraged to adopt the strategy.

In view of the conclusions of this systematic review, some recent developments in Brazil give cause for reflection. The first is the reduction in the pace of implementation of IMCI in the country owing to a change in the priorities of the Children's Health Department of the Ministry of Health. The second relates to the directive that medicines be prescribed only by a qualified physician, with nurses being responsible for health promotion and detection of signs of disease (or of the risk of disease). Finally, much effort is currently being invested in the establishment of adequate healthcare for children integrating of primary care health workers in a more complex system of reference.

Healthcare policies should be strongly based on scientific knowledge. In that respect, the findings of the present systematic review of the literature show that training in IMCI has led to significant improvements in children's health in Brazil.

Recebido em 19 de abril de 2007

Versão final apresentada em 5 de fevereiro de 2008

Aprovado para publicação em 2 de março de 2008

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Publication Dates

• Publication in this collection
  28 July 2008
• Date of issue
  Mar 2008

History

• Accepted
  02 Mar 2008
• Received
  19 Apr 2007