title: Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review.
abstract: OBJECTIVE
  Implementation of the Integrated Management of Childhood Illness (IMCI) strategy with an 11-day training course for health workers improves care for ill children in outpatient settings in developing countries. The 11-day course duration is recommended by the World Health Organization, which developed IMCI. Our aim was to determine if shortening the training (to reduce cost) reduces its effectiveness.
  
  
  METHODS
  We conducted a systematic review to compare IMCI's effectiveness with standard training (duration ≥ 11 days) versus shortened training (5-10 days). Studies were identified from a search of MEDLINE, two existing systematic reviews, and by contacting investigators. We included published or unpublished studies that evaluated IMCI's effectiveness in developing countries and reported quantitative measures of health worker practices related to managing ill children under 5 years old in public or private health facilities. Summary measures were the median of effect sizes for all outcomes from a given study, and the percentage of patients needing oral antimicrobials or rehydration who were treated according to IMCI guidelines.
  
  
  RESULTS
  Twenty-nine studies were included. Direct comparisons from three studies showed little difference between standard and shortened training. Indirect comparisons from 26 studies revealed that effect sizes for standard training versus no IMCI were greater than shortened training versus no IMCI. Across all comparisons, differences ranged from -3 to +23 percentage-points, and our best estimate was a 2 to 16 percentage-point advantage for standard training. No result was statistically significant. After IMCI training (of any duration), 34% of ill children needing oral antimicrobials or rehydration were not receiving these treatments according to IMCI guidelines.
  
  
  CONCLUSIONS
  Based on limited evidence, standard IMCI training seemed more effective than shortened training, although the difference might be small. As sizable performance gaps often existed after IMCI training, countries should consider implementing other interventions to support health workers after training, regardless of training duration.
authors.affiliation: Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Mailstop F22, 4770 Buford Highway, Atlanta, GA 30341-3724, USA. axr9@cdc.gov
authors.forename: Alexander K
authors.initials: AK
authors.lastname: Rowe
authors.forename: Samantha Y
authors.initials: SY
authors.lastname: Rowe
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Holloway
authors.forename: Verica
authors.initials: V
authors.lastname: Ivanovska
authors.forename: Lulu
authors.initials: L
authors.lastname: Muhe
authors.forename: Thierry
authors.initials: T
authors.lastname: Lambrechts
mesh_terms: D002648:Child; D002662:Child Health Services / Q000592:standards*; D019033:Delivery of Health Care, Integrated / Q000592:standards*; D003906:Developing Countries; D019468:Disease Management; D006282:Health Personnel / Q000193:education; D006801:Humans; D017410:Practice Guidelines as Topic; D013663:Teaching / Q000379:methods