Objective: To evaluate an intervention to promote health workers' use of the World Health Organization's Integrated Management of Childhood Illness clinical guidelines and to identify other factors influencing quality of care received by Moroccan children.
Setting: Public outpatient health facilities.
Design: Cross-sectional survey of consultations with sick children under 5 years old at facilities in two intervention and two comparison provinces in April 2000 (6-12 months after intervention). Consultations were observed, children's caretakers and health workers were interviewed, and children were re-examined by a 'gold standard' study clinician.
Study participants: Probability sample of 467 consultations (97.9% participation) performed by 101 health workers in 62 facilities.
Intervention: Health workers received in-service training with job aids and a follow-up visit with feedback 4-6 weeks after training.
Main outcome measures: Index of overall guideline adherence (mean percentage of recommended tasks that were done per child) and the percentage of children requiring antibiotics correctly prescribed antibiotics.
Results: Quality of care was better in intervention provinces, according to the adherence index (79.7 versus 19.5%, P < 0.0001), correct prescription of antibiotics (60.8 versus 31.3%, P = 0.0013), and other indicators. Multivariate modeling revealed a variety of factors significantly associated with quality, including health worker attributes (pre-service training, residence in government-subsidized housing, sex, and opinions) and child/consultation attributes (child's age and temperature, number of chief complaints, and caretaker type).
Conclusions: Exposure to the intervention was strongly associated with adherence to the guidelines and correct prescribing of antibiotics 6-12 months after exposure. Many other factors may influence health worker performance.