title: Improving private practitioner sick-child case management in two urban communities in Pakistan.
abstract: OBJECTIVE
  To evaluate if INFECTOM, a multicomponent behaviour change strategy, would alter the care received by children visiting private healthcare providers so that it was more consistent with the IMCI algorithm.
  
  
  METHODS
  Community surveys in two low income communities in Pakistan identified children who had visited healthcare providers in the preceding 2 weeks complaining of diarrhoea, cough or rapid breathing, or fever. Interviewers asked the mothers of these children whether providers performed specific behaviours recommended by the Integrated Management of Childhood Illness (IMCI) algorithm. These data were analysed to generate provider-specific IMCI-related behaviour profiles. A team including community representatives met with the providers, discussed the correct IMCI algorithm behaviour, reviewed the percentage of time each of their practices was consistent with IMCI recommendations, and negotiated a contract with a numerical target for improved practices. This cycle of survey, discussion of results and contracting was repeated three times over 10 months.
  
  
  RESULTS
  Twenty-two providers, 13 of whom (59%) had a medical degree, regularly treated children in the two communities. Sixteen of the 21 targeted behaviours (76%) occurred with significantly increased frequency during the course of the intervention. Of the 10 practices that ill children with any of the syndromes should have received, at baseline children averaged receiving 4.3. In the final model, each subsequent round of evaluation was associated with a 0.57 increase in the number of appropriate practices performed at visits to non-Bachelor's Degree in Medicine (MBBS) qualified providers (P < 0.001) and a 0.75 increase among visits to MBBS qualified providers (P=0.004). The percentage of children who received an injection decreased from 70 to 56% (P=0.03).
  
  
  CONCLUSIONS
  INFECTOM altered the practices of private providers so that they were more consistent with the IMCI algorithm. Efforts to further develop this approach could improve the quality of clinical healthcare in other settings.
authors.affiliation: Community Health Sciences Department, Aga Khan University, Karachi, Pakistan. sxl2@cdc.gov
authors.forename: Stephen
authors.initials: S
authors.lastname: Luby
authors.forename: Najam
authors.initials: N
authors.lastname: Zaidi
authors.forename: Simi
authors.initials: S
authors.lastname: Rehman
authors.forename: Robert
authors.initials: R
authors.lastname: Northrup
mesh_terms: D019090:Case Management / Q000458:organization & administration / Q000706:statistics & numerical data*; D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data*; D002983:Clinical Competence; D003153:Community Health Services / Q000458:organization & administration*; D004522:Educational Status; D006801:Humans; D010154:Pakistan; D011203:Poverty; D011331:Private Practice; D014505:Urban Population; D014838:Volunteers