Objective Integrated Management of Childhood Illness
(IMCI) is the leading clinical protocol designed to
decrease under-five mortality globally. However, impact
is threatened by gaps in IMCI quality of care (QOC). In
2010, Partners In Health and the Rwanda Ministry of
Health implemented a nurse mentorship intervention
Mentoring and Enhanced Supervision at Health Centres
(MESH) in two rural districts. This study measures
change in QOC following the addition of MESH to
didactic training.
Design Prepost intervention study of change in QOC
after 12 months of MESH support measured by case
observation using a standardised checklist. Study sample
was children age 2 months to 5 years presenting on the
days of data collection (292 baseline, 413 endpoint).
Setting 21 rural health centres in Rwanda.
Outcomes Primary outcome was a validated index of
key IMCI assessments. Secondary outcomes included
assessment, classification and treatment indicators, and
QOC variability across providers. A mixed-effects
regression model of the index was created.
Results In multivariate analyses, the index significantly
improved in southern Kayonza (β-coefficient 0.17, 95%
CI 0.12 to 0.22) and Kirehe (β-coefficient 0.29, 95% CI
0.23 to 0.34) districts. Children seen by IMCI-trained
nurses increased from 83.2% to 100% (p<0.001) and
use of IMCI case recording forms improved from 65.9%
to 97.1% (p<0.001). Correct classification improved
(56.0% to 91.5%, p<0.001), as did correct treatment
(78.3% to 98.2%, p<0.001). Variability in QOC
decreased (intracluster correlation coefficient 0.613–
0.346).
Conclusions MESH was associated with significant
improvements in all domains of IMCI quality. MESH
could be an innovative strategy to improve IMCI
implementation in resource-limited settings working to
decrease under-five mortality.