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Moon TD, Sumah I, Amorim G, Alhasan F, Howard LM, Myers H, Green AF, Grant DS, Schieffelin JS, Samuels RJ. Antibiotic prescribing practices for acute respiratory illness in children less than 24 months of age in Kenema, Sierra Leone: is it time to move beyond algorithm driven decision making? BMC Infect Dis 2023; 23:626. [PMID: 37749485 PMCID: PMC10519098 DOI: 10.1186/s12879-023-08606-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Lower respiratory tract infections are the leading cause of mortality in young children globally. In many resource-limited settings clinicians rely on guidelines such as IMCI or ETAT + that promote empiric antibiotic utilization for management of acute respiratory illness (ARI). Numerous evaluations of both guidelines have shown an overall positive response however, several challenges have also been reported, including the potential for over-prescribing of unnecessary antibiotics. The aims of this study were to describe the antibiotic prescribing practices for children less than 24 months of age with symptoms of ARI, that were admitted to Kenema Government Hospital (KGH) in the Eastern Province of Sierra Leone, and to identify the number of children empirically prescribed antibiotics who were admitted to hospital with ARI, as well as their clinical signs, symptoms, and outcomes. METHODS We conducted a prospective study of children < 24 months of age admitted to the KGH pediatric ward with respiratory symptoms between October 1, 2020 and May 31, 2022. Study nurses collected data on demographic information, medical and medication history, and information on clinical course while hospitalized. RESULTS A total of 777 children were enrolled. Prior to arrival at the hospital, 224 children (28.8%) reported taking an antibiotic for this illness without improvement. Only 15 (1.9%) children received a chest radiograph to aid in diagnosis and 100% of patients were placed on antibiotics during their hospital stay. CONCLUSIONS Despite the lives saved, reliance on clinical decision-support tools such as IMCI and ETAT + for pediatric ARI, is resulting in the likely over-prescribing of antibiotics. Greater uptake of implementation research is needed to develop strategies and tools designed to optimize antibiotic use for ARI in LMIC settings. Additionally, much greater priority needs to be given to ensuring clinicians have the basic tools for clinical diagnosis, as well as greater investments in essential laboratory and radiographic diagnostics that help LMIC clinicians move beyond the sole reliance on algorithm based clinical decision making.
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Affiliation(s)
- Troy D Moon
- Department of Tropical Medicine and Infectious Diseases, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2300, New Orleans, Louisiana, 70112, USA.
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Tulane University School of Medicine, 1440 Canal Street, Suite 1600, New Orleans, Louisiana, 70112, USA.
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN, 37203, USA.
| | - Ibrahim Sumah
- Kenema Government Hospital, Ministry of Health and Sanitation, 1 Combema Road, Kenema, Sierra Leone, Sierra Leone
| | - Gustavo Amorim
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1000, Nashville, TN, 37203, USA
| | - Foday Alhasan
- Kenema Government Hospital, Ministry of Health and Sanitation, 1 Combema Road, Kenema, Sierra Leone, Sierra Leone
| | - Leigh M Howard
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN, 37203, USA
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, D-7235 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Harriett Myers
- Department of Tropical Medicine and Infectious Diseases, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2300, New Orleans, Louisiana, 70112, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN, 37203, USA
| | - Ann F Green
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN, 37203, USA
| | - Donald S Grant
- Kenema Government Hospital, Ministry of Health and Sanitation, 1 Combema Road, Kenema, Sierra Leone, Sierra Leone
- College of Medicine and Allied Health Sciences, University of Sierra Leone, New England Ville, Freetown, Sierra Leone
| | - John S Schieffelin
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Tulane University School of Medicine, 1440 Canal Street, Suite 1600, New Orleans, Louisiana, 70112, USA
| | - Robert J Samuels
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN, 37203, USA
- Kenema Government Hospital, Ministry of Health and Sanitation, 1 Combema Road, Kenema, Sierra Leone, Sierra Leone
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The unfinished agenda of communicable diseases among children and adolescents before the COVID-19 pandemic, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019. Lancet 2023; 402:313-335. [PMID: 37393924 PMCID: PMC10375221 DOI: 10.1016/s0140-6736(23)00860-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/22/2023] [Accepted: 04/26/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Communicable disease control has long been a focus of global health policy. There have been substantial reductions in the burden and mortality of communicable diseases among children younger than 5 years, but we know less about this burden in older children and adolescents, and it is unclear whether current programmes and policies remain aligned with targets for intervention. This knowledge is especially important for policy and programmes in the context of the COVID-19 pandemic. We aimed to use the Global Burden of Disease (GBD) Study 2019 to systematically characterise the burden of communicable diseases across childhood and adolescence. METHODS In this systematic analysis of the GBD study from 1990 to 2019, all communicable diseases and their manifestations as modelled within GBD 2019 were included, categorised as 16 subgroups of common diseases or presentations. Data were reported for absolute count, prevalence, and incidence across measures of cause-specific mortality (deaths and years of life lost), disability (years lived with disability [YLDs]), and disease burden (disability-adjusted life-years [DALYs]) for children and adolescents aged 0-24 years. Data were reported across the Socio-demographic Index (SDI) and across time (1990-2019), and for 204 countries and territories. For HIV, we reported the mortality-to-incidence ratio (MIR) as a measure of health system performance. FINDINGS In 2019, there were 3·0 million deaths and 30·0 million years of healthy life lost to disability (as measured by YLDs), corresponding to 288·4 million DALYs from communicable diseases among children and adolescents globally (57·3% of total communicable disease burden across all ages). Over time, there has been a shift in communicable disease burden from young children to older children and adolescents (largely driven by the considerable reductions in children younger than 5 years and slower progress elsewhere), although children younger than 5 years still accounted for most of the communicable disease burden in 2019. Disease burden and mortality were predominantly in low-SDI settings, with high and high-middle SDI settings also having an appreciable burden of communicable disease morbidity (4·0 million YLDs in 2019 alone). Three cause groups (enteric infections, lower-respiratory-tract infections, and malaria) accounted for 59·8% of the global communicable disease burden in children and adolescents, with tuberculosis and HIV both emerging as important causes during adolescence. HIV was the only cause for which disease burden increased over time, particularly in children and adolescents older than 5 years, and especially in females. Excess MIRs for HIV were observed for males aged 15-19 years in low-SDI settings. INTERPRETATION Our analysis supports continued policy focus on enteric infections and lower-respiratory-tract infections, with orientation to children younger than 5 years in settings of low socioeconomic development. However, efforts should also be targeted to other conditions, particularly HIV, given its increased burden in older children and adolescents. Older children and adolescents also experience a large burden of communicable disease, further highlighting the need for efforts to extend beyond the first 5 years of life. Our analysis also identified substantial morbidity caused by communicable diseases affecting child and adolescent health across the world. FUNDING The Australian National Health and Medical Research Council Centre for Research Excellence for Driving Investment in Global Adolescent Health and the Bill & Melinda Gates Foundation.
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Mosisa D, Aboma M, Girma T, Shibru A. Determinants of diarrheal diseases among under five children in Jimma Geneti District, Oromia region, Ethiopia, 2020: a case-control study. BMC Pediatr 2021; 21:532. [PMID: 34847912 PMCID: PMC8630872 DOI: 10.1186/s12887-021-03022-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
Background Globally, in 2017, there were nearly 1.7 billion cases of childhood diarrheal diseases, and it is the second most important cause of morbidity and mortality among under-five children in low-income countries, including Ethiopia. Sanitary conditions, poor housing, an unsanitary environment, insufficient safe water supply, cohabitation with domestic animals that may carry human pathogens, and a lack of food storage facilities, in combination with socioeconomic and behavioral factors, are common causes of diarrhea disease and have had a significant impact on diarrhea incidence in the majority of developing countries. Methods A community-based unmatched case-control study was conducted on 407 systematically sampled under-five children of Jimma Geneti District (135 with diarrhea and 272 without diarrhea) from May 01 to 30, 2020. Data was collected using an interview administered questionnaire and observational checklist adapted from the WHO/UNICEF core questionnaire and other related literature. Descriptive, bivariate, and multivariate binary logistic regression analyses were done by using SPSS version 20.0. Result Sociodemographic determinants such as being a child of 12–23 months of age (AOR 3.3, 95% CI 1.68–6.46; P < 0.05) and mothers’/caregivers’ history of diarrheal diseases (AOR 7.38, 95% CI 3.12–17.44; P < 0.05) were significantly associated with diarrheal diseases among under-five children. Environmental and behavioral factors such as lack of a hand-washing facility near a latrine (AOR 5.22, 95% CI 3.94–26.49; P < 0.05), a lack of hand-washing practice at critical times (AOR 10.6, 95% CI 3.74–29.81; P < 0.05), improper domestic solid waste disposal (AOR 2.68, 95% CI 1.39–5.18; P < 0.05), and not being vaccinated against rotavirus (AOR 2.45, 95% CI 1.25–4.81; P < 0,05) were found important determinants of diarrheal diseases among under-five children. Conclusion The unavailability of a hand-washing facility nearby latrine, mothers’/caregivers’ history of the last 2 weeks’ diarrheal diseases, improper latrine utilization, lack of hand-washing practice at critical times, improper solid waste disposal practices, and rotavirus vaccination status were the determinants of diarrheal diseases among under-five children identified in this study. Thus, promoting the provision of continuous and modified health information programs for households on the importance of sanitation, personal hygiene, and vaccination against rotavirus is fundamental to decreasing the burden of diarrheal disease among under-five children.
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Affiliation(s)
- Dejene Mosisa
- Department of Public Health, Medicine and Health Sciences College, Ambo University, P.O.BOX:19, Ambo, Oromia, Ethiopia
| | - Mecha Aboma
- Department of Public Health, Medicine and Health Sciences College, Ambo University, P.O.BOX:19, Ambo, Oromia, Ethiopia.
| | - Teka Girma
- Department of Public Health, Medicine and Health Sciences College, Ambo University, P.O.BOX:19, Ambo, Oromia, Ethiopia
| | - Abera Shibru
- Department of Public Health, Medicine and Health Sciences College, Ambo University, P.O.BOX:19, Ambo, Oromia, Ethiopia
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Curran R, Murdoch J, Bachmann M, Bateman E, Cornick R, Picken S, Simelane ML, Fairall L. Addressing the quality of paediatric primary care: health worker and caregiver perspectives from a process evaluation of PACK child, a health systems intervention in South Africa. BMC Pediatr 2021; 21:58. [PMID: 33509149 PMCID: PMC7842050 DOI: 10.1186/s12887-021-02512-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The WHO’s Integrated Management of Childhood Illness (IMCI) has resulted in progress in addressing infant and child mortality. However, unmet needs of children continue to present a burden upon primary healthcare services. The capacity of services and quality of care offered require greater support to address these needs by extending and integrating curative and preventive care for the child with a long-term health condition and the child older than 5, not prioritised in IMCI. In response to these needs, the PACK Child intervention was developed and piloted in October 2017–February 2019 in the Western Cape Province of South Africa. We report health worker and caregiver perspectives of the existing paediatric primary care context as well as the extent to which PACK Child functions to address perceived problems within the current local healthcare system. Methods This process evaluation involved 52 individual interviews with caregivers, 10 focus group discussions with health workers, 3 individual interviews with trainers, and 31 training observations. Interviews and focus groups explored participants’ experiences of paediatric primary care, perspectives of the PACK Child intervention, and tensions with implementation in each context. Inductive thematic analysis was used to analyse verbatim interview and discussion transcripts. Results Perspectives of caregivers and health workers suggest an institutionalised focus of paediatric primary care to treating children’s symptoms as acute episodic conditions. Health workers’ reports imply that this focus is perpetuated by interactions between contextual features such as, IMCI policy, documentation-driven consultations, overcrowded clinics and verticalised care. Whilst these contextual conditions constrained health workers’ ability to translate skills developed within PACK Child training into practice, the intervention initiated expanded care of children 0–13 years and those with long-term health conditions, enhanced professional competence, improved teamwork and referrals, streamlined triaging, and facilitated probing for psychosocial risk. Conclusion PACK Child appears to be catalysing paediatric primary care to address the broader needs of children, including long-term health conditions and the identification of psychosocial problems. However, to maximise this requires primary care to re-orientate from risk minimisation on the day of attendance towards a view of the child beyond the day of presentation at clinics. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02512-7.
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Affiliation(s)
- Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa.
| | - Jamie Murdoch
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Sandra Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Makhosazana Lungile Simelane
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa.,King's Global Health Institute, King's College London, London, SE1 9NH, UK
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Improving the Assessment and Classification of Sick Children according to the Integrated Management of Childhood Illness (IMCI) Protocol at Sanja Primary Hospital, Northwest Ethiopia: A Pre-Post Interventional Study. Int J Pediatr 2020; 2020:2501932. [PMID: 33133198 PMCID: PMC7593754 DOI: 10.1155/2020/2501932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/02/2020] [Accepted: 10/10/2020] [Indexed: 01/16/2023] Open
Abstract
Background A complete and consistent use of integrated management of childhood illness (IMCI) protocol is a strategic implementation that has been used to promote the accurate assessment and classifications of childhood illnesses, ensures appropriate combined treatment, strengthens the counseling of caregiver, and speeds up the referrals to decrease child mortality and morbidity. However, there is limited evidence about the complete and consistent use of IMCI protocol during the assessment and classifications of childhood illness in Ethiopia. Therefore, this intervention was implemented to improve the assessment and classifications of childhood illness according to the IMCI protocol in Sanja primary hospital, northwest Ethiopia. Methods A pre-post interventional study was used in Sanja primary hospital from January 01 to May 30, 2019. A total of 762 (381 for pre and 381 for postintervention) children from 2 months up to 5 years of age were involved in the study. Data were collected using a structured questionnaire prepared from the IMCI guideline, and a facility checklist was used. A five-month in-service training, weekly supportive supervision, daily morning session, and availing essential drugs and materials were done. Both the descriptive statistics and independent t-test were done. In the independent t-test, a p value of <0.05 and a mean difference with 95% CI were used to declare the significance of the interventions. Results The findings revealed that the overall completeness of the assessment was improved from 37.8 to 79.8% (mean difference: 0.17; 95% CI: 0.10-0.22), consistency of assessment with classification from 47.5 to 76.9% (mean difference: 0.34; 95% CI: 0.27-0.39), classification with treatment from 42.3 to 75.4% (mean difference: 0.35; 95% CI: 0.28-0.47), and classification with follow-up from 32.8 to 73.0% (mean difference: 0.36; 95% CI: 0.29-0.42). Conclusion The intervention has a significant improvement in the assessment and classification of childhood illness according to the IMCI protocol. Therefore, steps must be taken to ensure high quality of training, adequate supervision including the observation of health workers managing sick children during supervisory visits, and a constant supply of essential drugs and job aids for successful implementation of IMCI in the hospital and also to other facilities.
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Murdoch J, Curran R, Cornick R, Picken S, Bachmann M, Bateman E, Simelane ML, Fairall L. Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child). BMC Health Serv Res 2020; 20:479. [PMID: 32471431 PMCID: PMC7257217 DOI: 10.1186/s12913-020-05201-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/08/2020] [Indexed: 12/05/2022] Open
Abstract
Background Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO’s Integrated Management of Childhood Illness programme, extending care of children under 5 years to those aged 0–13 years, those with chronic conditions needing regular follow-up, integration of curative and preventive measures and routine care of the well child. In 2017–2018, PACK Child was piloted in 10 primary healthcare facilities in the Western Cape Province. Here we report findings from an investigation into the contextual features of South African primary care that shaped how clinicians delivered the PACK Child intervention within clinical consultations. Methods Process evaluation using linguistic ethnographic methodology which provides analytical tools for investigating human behaviour, and the shifting meaning of talk and text within context. Methods included semi-structured interviews, focus groups, ethnographic observation, audio-recorded consultations and documentary analysis. Analysis focused on how mapped contextual features structured clinician-caregiver interactions. Results Primary healthcare facilities demonstrated an institutionalised orientation to minimising risk upheld by provincial documentation, providing curative episodic care to children presenting with acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all in children 5 years or younger. Children with chronic illnesses such as asthma rarely receive routine care. These contextual features constrained the ability of clinicians to use the PACK Child guide to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues, and navigate use of the guide alongside provincial documentation. Conclusion Our findings provide evidence that PACK Child is catalysing a transition to an approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.
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Affiliation(s)
- Jamie Murdoch
- School of Health Sciences, University of East Anglia, Edith Cavell Building, Colney Lane, Norwich, NR4 7TJ, UK.
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Sandy Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Makhosazana Lungile Simelane
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,King's Global Health Institute, King's College London, London, SE1 9NH, UK
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Getachew T, Mekonnen S, Yitayal M, Persson LÅ, Berhanu D. Health Extension Workers' diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross-sectional study. Acta Paediatr 2019; 108:2100-2106. [PMID: 31162734 PMCID: PMC7154548 DOI: 10.1111/apa.14888] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/27/2019] [Accepted: 06/03/2019] [Indexed: 01/18/2023]
Abstract
Aim The Ethiopian primary care of sick children is provided within the integrated Community Case Management of childhood illnesses by Health Extension Workers (HEW). There is limited knowledge whether this cadre correctly assess and classify common diseases. The aim was to study their ability to correctly classify common childhood illnesses. Methods A survey was conducted from December 2016 to February 2017 in four regions of Ethiopia. Observations of the HEWs‘ assessment and classification of sick children were followed by child re-examination by a trained health officer. Results The classification by the HEWs of 620 sick children as compared to the reexaminer had a sensitivity of 89% and specificity of 94% for diarrhoea, sensitivity 52% and specificity 91% for febrile disorders, and a sensitivity of 59% and specificity of 94% for acute respiratory tract infection. Malnutrition and ear infection had a sensitivity of 39 and 61%, and a specificity of 99 and 99%, respectively. Conclusion Most cases of diarrhoea were correctly classified, while other illnesses were not frequently identified. The identification of malnutrition was especially at fault. These findings suggest that a significant number of sick children were undiagnosed that could lead to absent or incorrect management and treatment.
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Affiliation(s)
- Theodros Getachew
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Solomon Mekonnen
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Mezgebu Yitayal
- College of Medicine and Health Science Institute of Public Health University of Gondar Gondar Ethiopia
| | - Lars Åke Persson
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene and Tropical Medicine Bloomsbury, London UK
| | - Della Berhanu
- Health System and Reproductive Health Research Directorate Ethiopian Public Health Institute Addis Ababa Ethiopia
- London School of Hygiene and Tropical Medicine Bloomsbury, London UK
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Robertson SK, Manson K, Fioratou E. IMCI and ETAT integration at a primary healthcare facility in Malawi: a human factors approach. BMC Health Serv Res 2018; 18:1014. [PMID: 30594185 PMCID: PMC6310991 DOI: 10.1186/s12913-018-3803-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integrated Management of Childhood Illness (IMCI) and Emergency Triage, Assessment and Treatment (ETAT) are guidelines developed by the World Health Organization to reach targets for reducing under-5 mortality. They were set out in the Millennium Development Goals. Each guideline was established separately so the purpose of this study was to understand how these systems have been integrated in a primary care setting and identify barriers and facilitators to this integration using a systems approach. METHOD Interviews were carried out with members of staff of different levels within a primary healthcare clinic in Malawi. Along with observations from the clinic this provided a well-rounded view of the running of the clinic. This data was then analysed using the SEIPS 2.0 work systems framework. The work system elements specified in this model were used to identify and categorise themes that influenced the clinic's efficiency. RESULTS A process map of the flow of patients through the clinic was created, showing the tasks undertaken and the interactions between staff and patients. In their interviews, staff identified several organisational elements that served as barriers to the implementation of care. They included workload, available resources, ineffective time management, delegation of roles and adaptation of care. In terms of the external environment there was a lack of clarity over the two sets of guidelines and how they were to be integrated which was a key barrier to the process. Under the heading of tools and technology a lack of guideline copies was identified as a barrier. However, the health passport system and other forms of recording were highlighted as being important facilitators. Other issues highlighted were the lack of transport provided, challenges regarding teamwork and attitudes of members of staff, patient factors such as their beliefs and regard for the care and education provided by the clinic. CONCLUSIONS This study provides the first information on the challenges and issues involved in combining IMCI and ETAT and identified a number of barriers. These barriers included a lack of resources, staff training and heavy workload. This provided areas to work on in order to improve implementation.
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Cornick R, Wattrus C, Eastman T, Ras CJ, Awotiwon A, Anderson L, Bateman E, Zepeda J, Zwarenstein M, Doherty T, Fairall L. Crossing borders: the PACK experience of spreading a complex health system intervention across low-income and middle-income countries. BMJ Glob Health 2018; 3:e001088. [PMID: 30483416 PMCID: PMC6231097 DOI: 10.1136/bmjgh-2018-001088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/14/2018] [Accepted: 09/14/2018] [Indexed: 12/12/2022] Open
Abstract
Developing a health system intervention that helps to improve primary care in a low-income and middle-income country (LMIC) is a considerable challenge; finding ways to spread that intervention to other LMICs is another. The Practical Approach to Care Kit (PACK) programme is a complex health system intervention that has been developed and adopted as policy in South Africa to improve and standardise primary care delivery. We have successfully spread PACK to several other LMICs, including Botswana, Brazil, Nigeria and Ethiopia. This paper describes our experiences of localising and implementing PACK in these countries, and our evolving mentorship model of localisation that entails our unit providing mentorship support to an in-country team to ensure that the programme is tailored to local resource constraints, burden of disease and on-the-ground realities. The iterative nature of the model's development meant that with each country experience, we could refine both the mentorship package and the programme itself with lessons from one country applied to the next-a 'learning health system' with global reach. While not yet formally evaluated, we appear to have created a feasible model for taking our health system intervention across more borders.
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Affiliation(s)
- Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Camilla Wattrus
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Tracy Eastman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Christy Joy Ras
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Ajibola Awotiwon
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Lauren Anderson
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Jorge Zepeda
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Merrick Zwarenstein
- Western University, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Tanya Doherty
- South African Medical Research Council and Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
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Picken S, Hannington J, Fairall L, Doherty T, Bateman E, Richards M, Wattrus C, Cornick R. PACK Child: the development of a practical guide to extend the scope of integrated primary care for children and young adolescents. BMJ Glob Health 2018; 3:e000957. [PMID: 30397519 PMCID: PMC6203049 DOI: 10.1136/bmjgh-2018-000957] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/21/2018] [Accepted: 09/22/2018] [Indexed: 02/03/2023] Open
Abstract
Pioneering strategies like WHO's Integrated Management of Childhood Illness (IMCI) have resulted in substantial progress in addressing infant and child mortality. However, large inequalities exist in access to and the quality of care provided in different regions of the world. In many low-income and middle-income countries, childhood mortality remains a major concern, and the needs of children present a large burden upon primary care services. The capacity of services and quality of care offered require greater support to address these needs and extend integrated curative and preventive care, specifically, for the well child, the child with a long-term health need and the child older than 5 years, not currently included in IMCI. In response to these needs, we have developed an innovative method, based on experience with a similar approach in adults, that expands the scope and reach of integrated management and training programmes for paediatric primary care. This paper describes the development and key features of the PACK Child clinical decision support tool for the care of children up to 13 years, and lessons learnt during its development.
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Affiliation(s)
- Sandy Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Juliet Hannington
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Mowbray, South Africa
| | - Tanya Doherty
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Mark Richards
- Department of Paediatrics and Child Health, Somerset Hospital, University of Cape Town, Green Point, South Africa
| | - Camilla Wattrus
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Mowbray, South Africa
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Murdoch J, Curran R, Bachmann M, Bateman E, Cornick RV, Doherty T, Picken SC, Simelane ML, Fairall L. Strengthening the quality of paediatric primary care: protocol for the process evaluation of a health systems intervention in South Africa. BMJ Glob Health 2018; 3:e000945. [PMID: 30397518 PMCID: PMC6203013 DOI: 10.1136/bmjgh-2018-000945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/04/2018] [Accepted: 07/13/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Despite significant reductions in mortality, preventable and treatable conditions remain the leading causes of death in children under five within South Africa. The WHO's Integrated Management of Childhood Illness (IMCI) programme has been widely implemented to address the most common causes of mortality in children under five. Although effective, limitations in IMCI scope and adherence have emerged. The Practical Approach to Care Kit (PACK) Child guide has been developed to expand on IMCI and address these limitations. It is intended as a clinical decision support tool for health workers with additional systems strengthening components, including active implementation and training strategy to address contextual and organisational factors hindering quality of care for children. Implementation is complex, requiring comprehensive pilot and process evaluation. The PACK Child pilot and feasibility study will sample 10 primary care facilities in the Western Cape Province. Staff will be trained to integrate the PACK Child guide into routine practice. The process evaluation will investigate implementation and health systems components to establish how to optimise delivery, strengthen IMCI principles and factors required to support effective and sustained uptake into everyday practice. METHODS Mixed method process evaluation. Qualitative data include interviews with managers, staff, caregivers and policymakers; observations of training, consultations and clinic flow. Quantitative data include training logs and staff questionnaires. Quantitative and qualitative analysis will be integrated to describe study sites and develop explanations for implementation variation. DISCUSSION The process evaluation will provide the opportunity to document implementation and refine the programme prior to a larger pragmatic trial or scale-up.
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Affiliation(s)
- Jamie Murdoch
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Ruth Vania Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Tanya Doherty
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sandra Claire Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
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Awor P, Peterson S, Gautham M. Delivering child health interventions through the private sector in low and middle income countries: challenges, opportunities, and potential next steps. BMJ 2018; 362:k2950. [PMID: 30061154 PMCID: PMC6063308 DOI: 10.1136/bmj.k2950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Universal health coverage requires both the public and private sectors to ensure quality, equity, and efficiency in health systems, say Phyllis Awor and colleagues
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Affiliation(s)
- Phyllis Awor
- Makerere University School of Public Health, Kampala, Uganda
| | - Stefan Peterson
- Makerere University School of Public Health, Kampala, Uganda
- Uppsala University, Sweden
- Unicef, New York, USA
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Gerensea H, Kebede A, Baraki Z, Berihu H, Zeru T, Birhane E, G/Her D, Hintsa S, Siyum H, Kahsay G, Gidey G, Teklay G, Mulatu G. Consistency of Integrated Management of Newborn and Childhood Illness (IMNCI) in Shire Governmental Health Institution in 2017. BMC Res Notes 2018; 11:476. [PMID: 30012196 PMCID: PMC6048809 DOI: 10.1186/s13104-018-3588-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 07/10/2018] [Indexed: 12/14/2022] Open
Abstract
Objective In an effort to reduce infant mortality and morbidity, the World Health Organization and other technical partners developed the Integrated Management of Newborn and Childhood Illness (IMNCI). This study focuses on assessment of consistency and completeness of integrated management of neonatal and child hood illness in primary health care units. Results A total of 384 cases were taken from 3562 cases both from young infant registration (under-2 month old) and child registration (2 months–5 year old). Out of 384 cases, 241 (62.8%) cases were correctly classified and 143 (37.2%) were incorrect classifications. Similarly 164 (42.7%) cases were treated correctly where as 220 (57.3%) treated incorrectly. Only 95 (24.7%) cases have given appropriate appointments where as 289 (75.3%) cases were appointed incorrectly. The overall consistency of IMNCI management is poor. Unless continuous follow up of and training was given, children are not treated as expected. More over using electronic method of IMNCI may alleviate the problem.
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Affiliation(s)
- Hadgu Gerensea
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia.
| | - Awoke Kebede
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Zeray Baraki
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Hagos Berihu
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Teklay Zeru
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Eskedar Birhane
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Dawit G/Her
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Solomun Hintsa
- School of Public Health, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Hailay Siyum
- School of Public Health, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Gizenesh Kahsay
- School of Public Health, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Gebreamlake Gidey
- Department of Midwifery, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Girmay Teklay
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Gebremeskel Mulatu
- School of Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
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Johansson EW, Nsona H, Carvajal-Aguirre L, Amouzou A, Hildenwall H. Determinants of Integrated Management of Childhood Illness (IMCI) non-severe pneumonia classification and care in Malawi health facilities: Analysis of a national facility census. J Glob Health 2018; 7:020408. [PMID: 29163934 PMCID: PMC5680530 DOI: 10.7189/jogh.07.020408] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Research shows inadequate Integrated Management of Childhood Illness (IMCI)-pneumonia care in various low-income settings but evidence is largely from small-scale studies with limited evidence of patient-, provider- and facility-levels determinants of IMCI non-severe pneumonia classification and its management. Methods The Malawi Service Provision Assessment 2013-2014 included 3149 outpatients aged 2-59 months with completed observations, interviews and re-examinations. Mixed-effects logistic regression models quantified the influence of patient-, provider and facility-level determinants on having IMCI non-severe pneumonia and its management in observed consultations. Findings Among 3149 eligible outpatients, 590 (18.7%) had IMCI non-severe pneumonia classification in re-examination. 228 (38.7%) classified cases received first-line antibiotics and 159 (26.9%) received no antibiotics. 18.6% with cough or difficult breathing had 60-second respiratory rates counted during consultations, and conducting this assessment was significantly associated with IMCI training ever received (odds ratio (OR) = 2.37, 95% confidence interval (CI): 1.29-4.31) and negative rapid diagnostic test results (OR = 3.21, 95% CI: 1.45-7.13). Older children had lower odds of assessments than infants (OR = 48-59 months: 0.35, 95% CI: 0.16-0.75). Children presenting with any of the following complaints also had reduced odds of assessment: fever, diarrhea, skin problem or any danger sign. First-line antibiotic treatment for classified cases was significantly associated with high temperatures (OR = 3.26, 95% CI: 1.24-8.55) while older children had reduced odds of first-line treatment compared to infants (OR = 48-59 months: 0.29, 95% CI: 0.10-0.83). RDT-confirmed malaria was a significant predictor of no antibiotic receipt for IMCI non-severe pneumonia (OR = 10.65, 95% CI: 2.39-47.36). Conclusions IMCI non-severe pneumonia care was sub-optimal in Malawi health facilities in 2013-2014 with inadequate assessments and prescribing practices that must be addressed to reduce this leading cause of mortality. Child's symptoms and age, malaria diagnosis and provider training were primary influences on assessment and treatment practices. Current evidence could be used to better target IMCI training and support to improve pneumonia care for sick children in Malawi facilities.
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Affiliation(s)
| | - Humphreys Nsona
- Integrated Management of Childhood Illness (IMCI) Unit, Ministry of Health, Lilongwe, Malawi
| | | | - Agbessi Amouzou
- Data and Analytics Section, United Nations Children's Fund, New York, New York, USA
| | - Helena Hildenwall
- Global Health - Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Krüger C, Heinzel-Gutenbrunner M, Ali M. Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys. BMC Health Serv Res 2017; 17:822. [PMID: 29237494 PMCID: PMC5729502 DOI: 10.1186/s12913-017-2781-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/06/2017] [Indexed: 01/29/2023] Open
Abstract
Background Integrated Management of Childhood Illness (IMCI) is regarded as a standard public health approach to lowering child mortality in developing countries. However, little is known about how health workers adhere to the guidelines at the national level in sub-Saharan African countries. Methods Data from the Service Provision Assessment surveys of Namibia (NA) (survey year: 2009), Kenya (KE) (2010), Tanzania (TZ) (2006) and Uganda (UG) (2007) were analysed for adherence to the IMCI guidelines by health workers. Potential influencing factors included the survey country, patient’s age, the different levels of the national health system, the training level of the health care provider (physician, non-physician clinician, nurse-midwife, auxiliary staff), and the status of re-training in IMCI. Results In total, 6856 children (NA: 1495; KE: 1890; TZ: 2469; UG: 1002 / male 51.2–53.5%) aged 2–73 months (2–24 months, 65.3%; median NA: 19 months; KE: 18 months; TZ: 16 months; UG: 15 months) were clinically assessed by 2006 health workers during the surveys. Less than 33% of the workers carried out assessment of all three IMCI danger signs, namely inability to eat/drink, vomiting everything, and febrile convulsions (NA: 11%; KE: 11%; TZ: 14%; UG: 31%) while the rate for assessing all three of the IMCI main symptoms of cough/difficult breathing, diarrhoea, and fever was < 60% (NA: 48%; KE: 34%; TZ: 50%; UG: 57%). Physical examination rates for fever (temperature) (NA: 97%; KE: 87%; TZ: 73%; UG: 90%), pneumonia (respiration rate/auscultation) (NA: 43%; KE: 24%; TZ: 25%; UG: 20%) and diarrhoea (dehydration status) (NA: 29%; KE: 19%; TZ: 20%; UG: 39%) varied widely and were highest when assessing children with the actual diagnosis of pneumonia and diarrhoea. Adherence rates tended to be higher in children ≤ 24 months, at hospitals, among higher-qualified staff (physician/non-physician clinician) and among those with recent IMCI re-training. Conclusion Despite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries. IMCI training should continue to be provided to all health staff, particularly nurses, midwives, and auxiliary staff, with periodic re-training and an emphasis to equally target children of all age groups.
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Affiliation(s)
- Carsten Krüger
- Department of Paediatrics, Witten/Herdecke University, Witten, Germany. .,Children's Hospital, St. Franziskus Hospital, Robert-Koch-Strasse 55, D-59227, Ahlen, Germany.
| | | | - Mohammed Ali
- Faculty of Health Sciences, School of Nursing, Midwifery & Paramedicine, Curtin University, Perth, Australia
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Mansoor GF, Chikvaidze P, Varkey S, Higgins-Steele A, Safi N, Mubasher A, Yusufi K, Alawi SA. Quality of child healthcare at primary healthcare facilities: a national assessment of the Integrated Management of Childhood Illnesses in Afghanistan. Int J Qual Health Care 2017; 29:55-62. [PMID: 27836999 DOI: 10.1093/intqhc/mzw135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/31/2016] [Indexed: 12/22/2022] Open
Abstract
Objective To assess quality of the national Integrated Management of Childhood Illness (IMCI) program services provided for sick children at primary health facilities in Afghanistan. Design Mixed methods including cross-sectional study. Setting Thirteen (of thirty-four) provinces in Afghanistan. Participants Observation of case management and re-examination of 177 sick children, exit interviews with caretakers and review of equipment/supplies at 44 health facilities. Intervention Introduction and scale up of Integrated Management of Childhood Illnesses at primary health care facilities. Main outcome measures Care of sick children according to IMCI guidelines, health worker skills and essential health system elements. Results Thirty-two (71%) of the health workers were trained in IMCI and five (11%) received supervision in clinical case management during the past 6 months. On average, 5.4 out of 10 main assessment tasks were performed during cases observed, the index being higher in children seen by trained providers than untrained (6.3 vs 3.5, 95% CI 5.8-6.8 vs 2.9-4.1). In all, 74% of the 104 children who needed oral antibiotics received prescriptions, while 30% received complete and correct advice and 30% were overprescribed, and more so by untrained providers. Home care counseling was associated with provider training status (41.3% by trained and 24.5% by untrained). Essential oral and pre-referral injectable medicine and equipment/supplies were available in 66%, 23%, and 45% of health facilities, respectively. Conclusion IMCI training improved assessment, rational use of antibiotics and counseling; further investment in IMCI in Afghanistan, continuing provider capacity building and supportive supervision for improved quality of care and counseling for sick children is needed, especially given high burden treatable childhood illness.
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Affiliation(s)
- Ghulam Farooq Mansoor
- Health Protection and Research Organization, House P 27, Street 1. Qala-e-Fathullah, District 10, Kabul City, Afghanistan
| | - Paata Chikvaidze
- World Health Organization, Afghanistan office: UNOCA Compound, Kabul Jalalabad High Way, Kabul city, Afghanistan
| | - Sherin Varkey
- United Nation's Children Fund (UNICEF) Country office, UNOCA Compound, Kabul Jalalabad High Way, Kabul city, Afghanistan
| | - Ariel Higgins-Steele
- United Nation's Children Fund (UNICEF) Country office, UNOCA Compound, Kabul Jalalabad High Way, Kabul city, Afghanistan
| | - Najibullah Safi
- Ministry of Public Health, Islamic Republic of Afghanistan, Great Masoud Square, Wazir Mohammad Akbar Khan, Kabul City, Afghanistan
| | - Adela Mubasher
- World Health Organization, Afghanistan office: UNOCA Compound, Kabul Jalalabad High Way, Kabul city, Afghanistan
| | - Khaksar Yusufi
- United Nation's Children Fund (UNICEF) Country office, UNOCA Compound, Kabul Jalalabad High Way, Kabul city, Afghanistan
| | - Sayed Alisha Alawi
- Ministry of Public Health, Islamic Republic of Afghanistan, Great Masoud Square, Wazir Mohammad Akbar Khan, Kabul City, Afghanistan
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Venkataramani M, Edward A, Ickx P, Younusi M, Ali Shah Alawi S, Peters DH. Are children presenting with non-IMCI complaints at greater risk for suboptimal screening? An analysis of outpatient visits in Afghanistan. Int J Qual Health Care 2017; 29:662-668. [PMID: 28992150 DOI: 10.1093/intqhc/mzx084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 07/03/2017] [Indexed: 11/13/2022] Open
Abstract
Objective To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions. Design Cross-sectional study. Setting Thirty-three provinces in Afghanistan. Participants Observation of 3072 sick child visits selected by systematic random sampling. Main outcome measure(s) A 10 point IMCI assessment index. Results One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52-1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25-1.26; P = 0.003). Conclusions Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.
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Affiliation(s)
- Maya Venkataramani
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Suite 2-502, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Paul Ickx
- Center for Health Services, Management Sciences for Health, 4301 Fairfax Dr, Arlington, VA 22203, USA
| | - Motawali Younusi
- Child and Adolescent Health Department, General Directorate of Preventive Medicine of the Ministry of Public Health of the Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - Syed Ali Shah Alawi
- Child and Adolescent Health Department, General Directorate of Preventive Medicine of the Ministry of Public Health of the Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
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Haque F, Ball RL, Khatun S, Ahmed M, Kache S, Chisti MJ, Sarker SA, Maples SD, Pieri D, Vardhan Korrapati T, Sarnquist C, Federspiel N, Rahman MW, Andrews JR, Rahman M, Nelson EJ. Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting. PLoS Negl Trop Dis 2017; 11:e0005290. [PMID: 28103233 PMCID: PMC5283765 DOI: 10.1371/journal.pntd.0005290] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/31/2017] [Accepted: 12/28/2016] [Indexed: 11/19/2022] Open
Abstract
The emergence of mobile technology offers new opportunities to improve clinical guideline adherence in resource-limited settings. We conducted a clinical pilot study in rural Bangladesh to evaluate the impact of a smartphone adaptation of the World Health Organization (WHO) diarrheal disease management guidelines, including a modality for age-based weight estimation. Software development was guided by end-user input and evaluated in a resource-limited district and sub-district hospital during the fall 2015 cholera season; both hospitals lacked scales which necessitated weight estimation. The study consisted of a 6 week pre-intervention and 6 week intervention period with a 10-day post-discharge follow-up. Standard of care was maintained throughout the study with the exception that admitting clinicians used the tool during the intervention. Inclusion criteria were patients two months of age and older with uncomplicated diarrheal disease. The primary outcome was adherence to guidelines for prescriptions of intravenous (IV) fluids, antibiotics and zinc. A total of 841 patients were enrolled (325 pre-intervention; 516 intervention). During the intervention, the proportion of prescriptions for IV fluids decreased at the district and sub-district hospitals (both p < 0.001) with risk ratios (RRs) of 0.5 and 0.2, respectively. However, when IV fluids were prescribed, the volume better adhered to recommendations. The proportion of prescriptions for the recommended antibiotic azithromycin increased (p < 0.001 district; p = 0.035 sub-district) with RRs of 6.9 (district) and 1.6 (sub-district) while prescriptions for other antibiotics decreased; zinc adherence increased. Limitations included an absence of a concurrent control group and no independent dehydration assessment during the pre-intervention. Despite limitations, opportunities were identified to improve clinical care, including better assessment, weight estimation, and fluid/ antibiotic selection. These findings demonstrate that a smartphone-based tool can improve guideline adherence. This study should serve as a catalyst for a randomized controlled trial to expand on the findings and address limitations.
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Affiliation(s)
- Farhana Haque
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
- Infectious Diseases Division (IDD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Robyn L. Ball
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, United States of America
| | - Selina Khatun
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Mujaddeed Ahmed
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Saraswati Kache
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stace D. Maples
- Geospatial Center, Stanford University Libraries, Stanford, California, United States of America
| | - Dane Pieri
- Independent Technology Developer, San Francisco, California, United States of America
| | | | - Clea Sarnquist
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Nancy Federspiel
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Muhammad Waliur Rahman
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
- Infectious Diseases Division (IDD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jason R. Andrews
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mahmudur Rahman
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Eric Jorge Nelson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
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Johansson EW, Selling KE, Nsona H, Mappin B, Gething PW, Petzold M, Peterson SS, Hildenwall H. Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census. Malar J 2016; 15:396. [PMID: 27488343 PMCID: PMC4972956 DOI: 10.1186/s12936-016-1439-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/11/2016] [Indexed: 11/16/2022] Open
Abstract
Background There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management. This study assessed integrated paediatric fever management using malaria rapid diagnostic tests (RDT) and Integrated Management of Childhood Illness (IMCI) guidelines, including the relationship between RDT-negative results and antibiotic over-treatment in Malawi health facilities in 2013–2014. Methods A Malawi national facility census included 1981 observed sick children aged 2–59 months with fever complaints. Weighted frequencies were tabulated for other complaints, assessments and prescriptions for RDT-confirmed malaria, IMCI-classified non-severe pneumonia, and clinical diarrhoea. Classification trees using model-based recursive partitioning estimated the association between RDT results and antibiotic over-treatment and learned the influence of 38 other input variables at patient-, provider- and facility-levels. Results Among 1981 clients, 72 % were tested or referred for malaria diagnosis and 85 % with RDT-confirmed malaria were prescribed first-line anti-malarials. Twenty-eight percent with IMCI-pneumonia were not prescribed antibiotics (under-treatment) and 59 % ‘without antibiotic need’ were prescribed antibiotics (over-treatment). Few clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18 %). RDT-negative children had 16.8 (95 % CI 8.6–32.7) times higher antibiotic over-treatment odds compared to RDT-positive cases conditioned by cough or difficult breathing complaints. Conclusions Integrated paediatric fever management was sub-optimal for completed assessments and antibiotic targeting despite common compliance to malaria treatment guidelines. RDT-negative results were strongly associated with antibiotic over-treatment conditioned by cough or difficult breathing complaints. A shift from malaria-focused ‘test and treat’ strategies toward ‘IMCI with testing’ is needed to improve quality fever care and rational use of both anti-malarials and antibiotics in line with recent global commitments to combat resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1439-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily White Johansson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden.
| | - Katarina Ekholm Selling
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Humphreys Nsona
- Integrated Management of Childhood Illness (IMCI) Unit, Ministry of Health, Lilongwe, Malawi
| | - Bonnie Mappin
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, UK
| | - Peter W Gething
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, UK
| | - Max Petzold
- The Sahlgrenska Academy, Center for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Swartling Peterson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden.,Global Health-Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helena Hildenwall
- Global Health-Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Johansson EW, Kitutu FE, Mayora C, Awor P, Peterson SS, Wamani H, Hildenwall H. It could be viral but you don't know, you have not diagnosed it: health worker challenges in managing non-malaria paediatric fevers in the low transmission area of Mbarara District, Uganda. Malar J 2016; 15:197. [PMID: 27066829 PMCID: PMC4827217 DOI: 10.1186/s12936-016-1257-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 03/31/2016] [Indexed: 11/25/2022] Open
Abstract
Background In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts. Methods A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria paediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children under 5 years of age in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria paediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a latent content analysis approach. Results Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms, and analysing other factors such as a child’s age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs and desire to know the ‘exact’ disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria paediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis. Conclusions Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe, non-malaria paediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g., integrated management of childhood illness) and fostering communities of practice according to the diffusion of innovations theory.
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Affiliation(s)
| | - Freddy Eric Kitutu
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda
| | - Chrispus Mayora
- Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Phyllis Awor
- Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stefan Swartling Peterson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda.,Karolinska Institute, Global Health-Health Systems and Policy Research Group, Stockholm, Sweden
| | - Henry Wamani
- Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda
| | - Helena Hildenwall
- Karolinska Institute, Global Health-Health Systems and Policy Research Group, Stockholm, Sweden
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George A, Rodríguez DC, Rasanathan K, Brandes N, Bennett S. iCCM policy analysis: strategic contributions to understanding its character, design and scale up in sub-Saharan Africa. Health Policy Plan 2015; 30 Suppl 2:ii3-ii11. [DOI: 10.1093/heapol/czv096] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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22
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Fairall L, Bateman E, Cornick R, Faris G, Timmerman V, Folb N, Bachmann M, Zwarenstein M, Smith R. Innovating to improve primary care in less developed countries: towards a global model. ACTA ACUST UNITED AC 2015; 1:196-203. [PMID: 26692199 PMCID: PMC4680195 DOI: 10.1136/bmjinnov-2015-000045] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/16/2015] [Indexed: 11/21/2022]
Abstract
One of the biggest problems in global health is the lack of well trained and supported health workers in less developed settings. In many rural areas there are no physicians, and it is important to find ways to support and empower nurses and other health workers. The Knowledge Translation Unit of the University of Cape Town Lung Institute has spent 14 years developing a series of innovative packages to support and empower nurses and other health workers. PACK (Practical Approach to Care Kit) Adult comprises policy-based and evidence-informed guidelines; onsite, team and case-based training; non-physician prescribing; and a cascade system of scaling up. A series of randomised trials has shown the effectiveness of the packages, and methods are now being developed to respond cost-effectively and sustainably to global demand for implementing PACK Adult. Global health would probably benefit from less time and money spent developing new innovations and more spent on finding ways to spread those we already have.
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Affiliation(s)
- Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa
| | - Gill Faris
- Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa
| | - Venessa Timmerman
- Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa
| | - Max Bachmann
- Health Services Research, Norwich Medical School, University of East Anglia, UK
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23
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Ruhago GM, Ngalesoni FN, Robberstad B, Norheim OF. Cost-effectiveness of live oral attenuated human rotavirus vaccine in Tanzania. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2015; 13:7. [PMID: 25949216 PMCID: PMC4422135 DOI: 10.1186/s12962-015-0033-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, diarrhoea is the second leading cause of morbidity and mortality, responsible for the annual loss of about 10% of the total global childhood disease burden. In Tanzania, Rotavirus infection is the major cause of severe diarrhoea and diarrhoeal mortality in children under five years. Immunisation can reduce the burden, and Tanzania added rotavirus vaccine to its national immunisation programme in January 2013. This study explores the cost effectiveness of introducing rotavirus vaccine within the Tanzania Expanded Programme on Immunisation (EPI). METHODS We quantified all health system implementation costs, including programme costs, to calculate the cost effectiveness of adding rotavirus immunisation to EPI and the existing provision of diarrhoea treatment (oral rehydration salts and intravenous fluids) to children. We used ingredients and step down costing methods. Cost and coverage data were collected in 2012 at one urban and one rural district hospital and a health centre in Tanzania. We used Disability Adjusted Life Years (DALYs) as the outcome measure and estimated incremental costs and health outcomes using a Markov transition model with weekly cycles up to a five-year time horizon. RESULTS The average unit cost per vaccine dose at 93% coverage is US$ 8.4, with marked difference between the urban facility US$ 5.2; and the rural facility US$ 9.8. RV1 vaccine added to current diarrhoea treatment is highly cost effective compared to diarrhoea treatment given alone, with incremental cost effectiveness ratio of US$ 112 per DALY averted, varying from US$ 80-218 in sensitivity analysis. The intervention approaches a 100% probability of being cost effective at a much lower level of willingness-to-pay than the US$609 per capita Tanzania gross domestic product (GDP). CONCLUSIONS The combination of rotavirus immunisation with diarrhoea treatment is likely to be cost effective when willingness to pay for health is higher than USD 112 per DALY. Universal coverage of the vaccine will accelerate progress towards achievement of the child health Millennium Development Goals.
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Affiliation(s)
- George M Ruhago
- School of Public Health and Social Sciences, Muhimbili University, P.O Box 65015, Dar es Salaam, Tanzania ; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Frida N Ngalesoni
- Ministry of Health and Social Welfare, P.O Box 9083, Dar es Salaam, Tanzania ; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Centre for International Health, University of Bergen, Bergen, Norway
| | - Ole F Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Bulled N, Singer M, Dillingham R. The syndemics of childhood diarrhoea: a biosocial perspective on efforts to combat global inequities in diarrhoea-related morbidity and mortality. Glob Public Health 2014; 9:841-53. [PMID: 25005132 DOI: 10.1080/17441692.2014.924022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diarrhoea remains the second leading cause of death in children under 5 years. Moreover, morbidity as a result of diarrhoea is high particularly in marginalised communities. Frequent bouts of diarrhoea have deleterious and irreversible effects on physical and cognitive development. Children are especially vulnerable given their inability to mount an active immune response to pathogen exposure. Biological limitations are exacerbated by the long-term effects of poverty, including reduced nutrition, poor hygiene and deprived home environments. Drawing from available literature, this paper uses syndemic theory to explore the role of adverse biosocial interactions in increasing the total disease burden of enteric infections in low-resources populations and assesses the limitations of recent global calls to action. The syndemic perspective describes situations in which adverse social conditions, including inequality, poverty and other forms of political and economic oppression, play a critical role in facilitating disease-disease interactions. Given the complex micro- and macro-nature of childhood diarrhoea, including interactions between pathogens, disease conditions and social environments, the syndemic perspective offers a way forward. While rarely the focus of health interventions, technologically advanced biomedical strategies are likely to be more effective if coupled with interventions that address the social conditions of disparity.
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Affiliation(s)
- Nicola Bulled
- a The Center for Global Health , University of Virginia , Charlottesville , VA , USA
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25
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Druetz T, Siekmans K, Goossens S, Ridde V, Haddad S. The community case management of pneumonia in Africa: a review of the evidence. Health Policy Plan 2013; 30:253-66. [PMID: 24371218 DOI: 10.1093/heapol/czt104] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pneumonia causes around 750 000 child deaths per year in sub-Saharan African (SSA) countries. The lack of accessibility to prompt and effective treatment is an important contributor to this burden. Community case management of pneumonia (CCMp) uses trained community health workers (CHWs) to administer antibiotics to suspected child pneumonia cases in villages. This strategy has been gaining momentum in low- and middle-income countries, and the World Health Organization and United Nations children's fund have recently encouraged countries to broaden community case management to other diseases. Recommendations in favour CCMp are based on three meta-analyses showing its efficacy to reduce childhood mortality and morbidity attributable to pneumonia although most of the studies in the meta-analyses were conducted in Asian countries. This is problematic as community case management strategies have been implemented in very different ways in Asian and SSA countries, partly due to differences in malaria prevalence. Therefore, we conducted a narrative synthesis to systematically review the evidence on CCMp in SSA. Results show that there is a lack of evidence concerning its efficacy and effectiveness in SSA, irrespective of whether case management is integrated with other diseases or not. CHWs encounter difficulties in counting the respiratory rate. Their adherence to the guidelines is poorer when they are required to manage several illnesses or children with severe signs. CCMp thus encompasses issues of over-treatment and missed treatment, with potentially negative consequences such as increased lethality in severe cases and antibiotics resistance. The current lack of evidence concerning its efficacy, effectiveness and the factors leading to successful implementation, coupled with CHWs' poor adherence, demand a thorough examination of the legitimacy of implementing CCMp in SSA countries.
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Affiliation(s)
- Thomas Druetz
- Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France
| | - Kendra Siekmans
- Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France
| | - Sylvie Goossens
- Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France
| | - Valéry Ridde
- Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France
| | - Slim Haddad
- Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France Research Centre of the University of Montreal Hospital Centre (CRCHUM), 850 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC H3N 1X9, Canada Healthbridge, 1 Nicholas Street, Ottawa, ON K1N 7B7, Canada and Independent Consultant, Paris, France
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26
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Frieden TR. Six components necessary for effective public health program implementation. Am J Public Health 2013; 104:17-22. [PMID: 24228653 DOI: 10.2105/ajph.2013.301608] [Citation(s) in RCA: 173] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Public health programs succeed and survive if organizations and coalitions address 6 key areas. (1) Innovation to develop the evidence base for action; (2) a technical package of a limited number of high-priority, evidence-based interventions that together will have a major impact; (3) effective performance management, especially through rigorous, real-time monitoring, evaluation, and program improvement; (4) partnerships and coalitions with public- and private-sector organizations; (5) communication of accurate and timely information to the health care community, decision makers, and the public to effect behavior change and engage civil society; and (6) political commitment to obtain resources and support for effective action. Programs including smallpox eradication, tuberculosis control, tobacco control, polio eradication, and others have made progress by addressing these 6 areas.
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Affiliation(s)
- Thomas R Frieden
- Thomas R. Frieden is director of the Centers for Disease Control and Prevention, Atlanta, GA
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27
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Hoque DME, Arifeen SE, Rahman M, Chowdhury EK, Haque TM, Begum K, Hossain MA, Akter T, Haque F, Anwar T, Billah SM, Rahman AE, Huque MH, Christou A, Baqui AH, Bryce J, Black RE. Improving and sustaining quality of child health care through IMCI training and supervision: experience from rural Bangladesh. Health Policy Plan 2013; 29:753-62. [PMID: 24038076 DOI: 10.1093/heapol/czt059] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Integrated Management of Childhood Illness (IMCI) strategy includes guidelines for the management of sick children at first-level facilities. These guidelines intend to improve quality of care by ensuring a complete assessment of the child's health and by providing algorithms that combine presenting symptoms into a set of illness classifications for management by IMCI-trained service providers at first-level facilities. OBJECTIVES To investigate the sustainability of improvements in under-five case management by two cadres of first-level government service providers with different levels of pre-service training following implementation of IMCI training and supportive supervision. METHODS Twenty first-level health facilities in the rural sub-district of Matlab in Bangladesh were randomly assigned to IMCI intervention or comparison groups. Health workers in IMCI facilities received training in case management and monthly supportive supervision that involved observations of case management and reinforcement of skills by trained physicians. Health workers in comparison facilities were supervised according to Government of Bangladesh standards. Health facility surveys involving observations of case management were carried out at baseline (2000) and at two points (2003 and 2005) after implementation of IMCI in intervention facilities. FINDINGS Improvement in the management of sick under-five children by IMCI trained service providers with only 18 months of pre-service training was equivalent to that of service providers with 4 years of pre-service training. The improvements in quality of care were sustained over a 2-year period across both cadres of providers in intervention facilities. CONCLUSION IMCI training coupled with regular supervision can sustain improvements in the quality of child health care in first-level health facilities, even among workers with minimal pre-service training. These findings can guide government policy makers and provide further evidence to support the scale-up of regular supervision and task shifting the management of sick under-five children to lower-level service providers.
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Affiliation(s)
- D M Emdadul Hoque
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shams E Arifeen
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Muntasirur Rahman
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Enayet K Chowdhury
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Twaha M Haque
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Khadija Begum
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M Altaf Hossain
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tasnima Akter
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Fazlul Haque
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tariq Anwar
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sk Masum Billah
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmed Ehsanur Rahman
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Md Hamidul Huque
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aliki Christou
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Abdullah H Baqui
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Bryce
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert E Black
- Centre for Child and Adolescent Health (CCAH), ICDDR,B, Dhaka, Bangladesh, Director General of Health Services, Ministry of Health and Family Welfare, Bangladesh and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Does integrated management of childhood illness (IMCI) training improve the skills of health workers? A systematic review and meta-analysis. PLoS One 2013; 8:e66030. [PMID: 23776599 PMCID: PMC3680429 DOI: 10.1371/journal.pone.0066030] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 05/05/2013] [Indexed: 12/04/2022] Open
Abstract
Background An estimated 6.9 million children die annually in low and middle-income countries because of treatable illneses including pneumonia, diarrhea, and malaria. To reduce morbidity and mortality, the Integrated Management of Childhood Illness strategy was developed, which included a component to strengthen the skills of health workers in identifying and managing these conditions. A systematic review and meta-analysis were conducted to determine whether IMCI training actually improves performance. Methods Database searches of CIHAHL, CENTRAL, EMBASE, Global Health, Medline, Ovid Healthstar, and PubMed were performed from 1990 to February 2013, and supplemented with grey literature searches and reviews of bibliographies. Studies were included if they compared the performance of IMCI and non-IMCI health workers in illness classification, prescription of medications, vaccinations, and counseling on nutrition and admistration of oral therapies. Dersminion-Laird random effect models were used to summarize the effect estimates. Results The systematic review and meta-analysis included 46 and 26 studies, respectively. Four cluster-randomized controlled trials, seven pre-post studies, and 15 cross-sectional studies were included. Findings were heterogeneous across performance domains with evidence of effect modification by health worker performance at baseline. Overall, IMCI-trained workers were more likely to correctly classify illnesses (RR = 1.93, 95% CI: 1.66–2.24). Studies of workers with lower baseline performance showed greater improvements in prescribing medications (RR = 3.08, 95% CI: 2.04–4.66), vaccinating children (RR = 3.45, 95% CI: 1.49–8.01), and counseling families on adequate nutrition (RR = 10.12, 95% CI: 6.03–16.99) and administering oral therapies (RR = 3.76, 95% CI: 2.30–6.13). Trends toward greater training benefits were observed in studies that were conducted in lower resource settings and reported greater supervision. Conclusion Findings suggest that IMCI training improves health worker performance. However, these estimates need to be interpreted cautiously given the observational nature of the studies and presence of heterogeneity.
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Wilmshurst JM, Cross JH, Newton C, Kakooza AM, Wammanda RD, Mallewa M, Samia P, Venter A, Hirtz D, Chugani H. Children with epilepsy in Africa: recommendations from the International Child Neurology Association/African Child Neurology Association Workshop. J Child Neurol 2013; 28:633-44. [PMID: 23539548 DOI: 10.1177/0883073813482974] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This article presents key findings from the International Child Neurology Association/African Child Neurology Association Workshop. The viability of international guidelines for the management of children with epilepsy should be reviewed within each African country, and adapted to comply with the regional capacity. Such recommendations can be used to lobby for resources. More training centers should be developed in Africa, so that specialists can be trained within Africa, in skills relevant to the continent, in collaboration with "out of Africa" visiting-specialists to develop the concept of "train the trainers." At least 1 child neurology specialist per 100,000 of the population is required. Specific to Africa are the challenges from stigma, prejudice, and misconceptions. "Epilepsy teams," inclusive of the traditional healers, would enable management of increased numbers of children, and challenge policy such that it is the right of the child with epilepsy to have reliable access to appropriate antiepileptic drugs, support, and health care equity between the rural and urban settings.
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Affiliation(s)
- Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross Children's Hospital, School of Child and Adolescent Health, University of Cape Town, South Africa.
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30
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Gill CJ, Young M, Schroder K, Carvajal-Velez L, McNabb M, Aboubaker S, Qazi S, Bhutta ZA. Bottlenecks, barriers, and solutions: results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths. Lancet 2013; 381:1487-98. [PMID: 23582720 DOI: 10.1016/s0140-6736(13)60314-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Millions of children still die unnecessarily from pneumonia and diarrhoea, mainly in resource-poor settings. A series of collaborative consultations and workshops involving several hundred academic, public health, governmental and private sector stakeholders were convened to identify the key barriers to progress and to issue recommendations. Bottlenecks impairing access to commodities included antiquated supply management systems, insufficient funding for drugs, inadequate knowledge about interventions by clients and providers, health worker shortages, poor support for training or retention of health workers, and a failure to convert national policies into action plans. Key programmatic barriers included an absence of effective programme coordination between and within partner organisations, scarce financial resources, inadequate training and support for health workers, sporadic availability of key commodities, and suboptimal programme management. However, these problems are solvable. Advocacy could help to mobilise needed resources, raise awareness, and prioritise childhood pneumonia and diarrhoea deaths in the coming decade.
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