Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes

BACKGROUND

Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI.

METHODS

We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI.

RESULTS

Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained.

CONCLUSIONS

Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa

BACKGROUND

Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa.

METHODS

We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert.

RESULTS

Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants.

CONCLUSIONS

Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.

Challenges of using e-health technologies to support clinical care in rural Africa: a longitudinal mixed methods study exploring primary health care nurses' experiences of using an electronic clinical decision support system (CDSS) in South Africa

BACKGROUND

Electronic decision-making support systems (CDSSs) can support clinicians to make evidence-based, rational clinical decisions about patient management and have been effectively implemented in high-income settings. Integrated Management of Childhood Illness (IMCI) uses clinical algorithms to provide guidelines for management of sick children in primary health care clinics and is widely implemented in low income countries. A CDSS based on IMCI (eIMCI) was developed in South Africa.

METHODS

We undertook a mixed methods study to prospectively explore experiences of implementation from the perspective of newly-trained eIMCI practitioners. eIMCI uptake was monitored throughout implementation. In-depth interviews (IDIs) were conducted with selected participants before and after training, after mentoring, and after 6 months implementation. Participants were then invited to participate in focus group discussions (FGDs) to provide further insights into barriers to eIMCI implementation.

RESULTS

We conducted 36 IDIs with 9 participants between October 2020 and May 2021, and three FGDs with 11 participants in October 2021. Most participants spoke positively about eIMCI reporting that it was well received in the clinics, was simple to use, and improved the quality of clinical assessments. However, uptake of eIMCI across participating clinics was poor. Challenges reported included lack of computer skills which made simple tasks, like logging in or entering patient details, time consuming. Technical support was provided, but was time consuming to access so that eIMCI was sometimes unavailable. Other challenges included heavy workloads, and the perception that eIMCI took longer and disrupted participant's work. Poor alignment between recording requirements of eIMCI and other clinic programmes increased participant's administrative workload. All these factors were a disincentive to eIMCI uptake, frequently leading participants to revert to paper IMCI which was quicker and where they felt more confident.

CONCLUSION

Despite the potential of CDSSs to increase adherence to guidelines and improve clinical management and prescribing practices in resource constrained settings where clinical support is scarce, they have not been widely implemented. Careful attention should be paid to the work environment, work flow and skills of health workers prior to implementation, and ongoing health system support is required if health workers are to adopt these approaches (350).

Evaluation of the routine implementation of pulse oximeters into integrated management of childhood illness (IMCI) guidelines at primary health care level in West Africa: the AIRE mixed-methods research protocol

BACKGROUND

The AIRE operational project will evaluate the implementation of the routine Pulse Oximeter (PO) use in the integrated management of childhood illness (IMCI) strategy for children under-5 in primary health care centers (PHC) in West Africa. The introduction of PO should promote the accurate identification of hypoxemia (pulse blood oxygen saturation Sp02 < 90%) among all severe IMCI cases (respiratory and non-respiratory) to prompt their effective case management (oxygen, antibiotics and other required treatments) at hospital. We seek to understand how the routine use of PO integrated in IMCI outpatients works (or not), for whom, in what contexts and with what outcomes.

METHODS

The AIRE project is being implemented from 03/2020 to 12/2022 in 202 PHCs in four West African countries (Burkina Faso, Guinea, Mali, Niger) including 16 research PHCs (four per country). The research protocol will assess three complementary components using mixed quantitative and qualitative methods: a) context based on repeated cross-sectional surveys: baseline and aggregated monthly data from all PHCs on infrastructure, staffing, accessibility, equipment, PO use, severe cases and care; b) the process across PHCs by assessing acceptability, fidelity, implementation challenges and realistic evaluation, and c) individual outcomes in the research PHCs: all children under-5 attending IMCI clinics, eligible for PO use will be included with parental consent in a cross-sectional study. Among them, severe IMCI cases will be followed in a prospective cohort to assess their health status at 14 days. We will analyze pathways, patterns of care, and costs of care.

DISCUSSION

This research will identify challenges to the systematic implementation of PO in IMCI consultations, such as health workers practices, frequent turnover, quality of care, etc. Further research will be needed to fully address key questions such as the best time to introduce PO into the IMCI process, the best SpO2 threshold for deciding on hospital referral, and assessing the cost-effectiveness of PO use. The AIRE research will provide health policy makers in West Africa with sufficient evidence on the context, process and outcomes of using PO integrated into IMCI to promote scale-up in all PHCs.

TRIAL REGISTRATION

Trial registration number: PACTR202206525204526 retrospectively registered on 06/15/2022.

Assessing the quality of care in sick child services at health facilities in Ethiopia

Background

Quality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia.

Methods

Data from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction.

Result

Among children diagnosed with suspected pneumonia, respiratory rate was counted in 56% and temperature was checked in 77% of the cases. A majority of children (92%) diagnosed with fever had their temperature taken. Only 3% of children with fever were either referred or admitted, and 60% received antibiotics. Among children diagnosed with malaria, 51% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4% were assessed for all three general danger signs. Providers assessed dehydration in 54% of children with diarrhea with dehydration, 17% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients’ satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2 years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction.

Conclusion

The assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client’s satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania

Background

This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts.

Methods

From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy.

Results

The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2–85.6 in the intervention group and 82.7/1000 (95% CI 78.5–87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88–1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3–77.3) in the intervention group and 77.4/1000 (95% CI 73.8–81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86–1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89–1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74–1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1–59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76–0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85–1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07–1·88], p = 0·015).

Conclusions

Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months.

Trial registration

Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

Large-scale implementation of electronic Integrated Management of Childhood Illness (eIMCI) at the primary care level in Burkina Faso: a qualitative study on health worker perception of its medical content, usability and impact on antibiotic prescription and resistance

Background

Electronic clinical decision algorithms (eCDAs) that guide clinicians during patient management are being deployed in resource-limited settings to improve the quality of care and rational use of medicines (especially antimicrobials). Little is known on how local clinicians perceive the use and impact of these tools in their daily practice. This study investigates clinician insights on an eIMCI tool. Specifically, we report their views on its medical content, assess their knowledge on microbes, antimicrobials and the development of resistance.

Methods

This qualitative study was conducted in the frame of a large-scale implementation in Burkina Faso of an eIMCI tool developed by the Swiss NGO Terre des hommes. Twelve in-depth interviews and 2 focus-group discussions were conducted including 21 health workers from 10 primary care facilities. Emerging themes were identified using qualitative data analysis software.

Results

eIMCI users expressed a high level of satisfaction, slowness of the tablet was perceived as the major inconvenience limiting uptake. Several frequent illnesses were identified as missing in the algorithm along with guidance for fever without focus. When asked about existing types of microbes, 9 and 4 out of 21 participants could mention bacteria and virus respectively; only 5 correctly answered that antibiotics had no action on viral disease and 6 mentioned the risk of antibiotic resistance. Level of knowledge was higher in nurses than in less trained health workers. The tool was perceived as improving patient management and the rational use of antibiotics. Positive changes in health facility organisation were reported, such as task shifting and improved triage. eIMCI was also perceived as a learning tool, and users expressed a strong desire to expand the geographic and temporal scope of the intervention.

Conclusion

The use of eICMI was widely accepted and perceived as a powerful tool guiding daily practice. Findings suggest that it has positive effects on the health care system beyond the quality of consultation. To support large uptake and sustainability, better training of health workers in infectiology is essential and the medical content of eIMCI should be optimized to include frequent diseases and, for each of them, the appropriate management plan.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6692-6) contains supplementary material, which is available to authorized users.

Agreement Between Integrated Management of Childhood Illness and Final Diagnosis in Acute Respiratory Tract Infections

OBJECTIVE

To evaluate the agreement between integrated management of childhood illness (IMCI) and final diagnosis in patients presenting with cough at the second and third level health institutions.

METHODS

This cross-sectional study included 373 children aged 2-60 mo who presented with cough at the pediatric emergency and outpatient clinics in the Department of Pediatrics. After clinical examination of children, body temperature, respiratory rate, saturation, presence or absence of the chest indrawing, rales, wheezing and laryngeal stridor were recorded. Cases were categorized according to IMCI algorithm regarding the severity using the color code, such as red (urgent treatment), yellow (treatment in the hospital), or green (treatment at home). Final diagnosis after physical examination, laboratory analysis and chest X-ray was compared with the IMCI algorithm.

RESULTS

Study agreement between IMCI classification and final diagnosis was 74.3% with kappa value 0.55 (moderate agreement). Similar agreement values were detected in both the second and third level health institutions. Health condition and gender did not affect agreement value. Agreement were found to be high in patients <24 mo of age (ĸ = 0.67), presence of fever and cough (ĸ = 0.54), tachypnea (ĸ = 0.93), chest indrawing (ĸ = 1.00) and oxygen saturation of <94%(ĸ = 0.90).

CONCLUSIONS

Adding saturation level to the IMCI algorithmic diagnosis may increase agreement between IMCI classification and final diagnosis.

Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys

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.

Community Integrated Management of Childhood Illnesses (C-IMCI) and Key Household Practices in Kano, Northwest Nigeria

Introduction

Integrated Management of Childhood Illnesses (IMCI) is a holistic approach to reducing under-five morbidity and mortality and improving growth and development of children. This study compared key household and community practices in IMCI implementing and non-implementing communities in two local government areas (LGAs) of Kano State, Nigeria.

Methodology

A cross sectional study was employed with multistage cluster sampling selection of caregivers of children 0-59 months of age and their index children (n=400).The study was conducted from February 2009 through January 2010. Data analysis was performed using EpiInfo™v6.0 and Minitab™ software.

Results

The adoption of IMCI key household and community practices was generally better in IMCI-implementing communities than in non-IMCI communities. Exclusive breastfeeding (EBF) rate among children under six months was higher in IMCI communities than in non-IMCI communities (p=0.05). Non-IMCI communities also had a greater proportion of low weight-for-age children (42.5%) than IMCI communities. Mothers from IMCI communities (30.5%) were more likely to have antenatal care (ANC) during the first trimester than those from non-IMCI communities (p<0.05). There was no difference between the study communities with regard to use of insecticide treated nets during pregnancy (p=0.09), and having skilled attendance during last child birth (p=0.23).

Conclusion

Mothers in communities implementing IMCI are more likely to adopt EBF and to attend ANC services than their counterparts in communities not implementing IMCI. Expanding IMCI activities to other LGAs in northwest Nigeria will have a positive impact on reducing morbidity from common childhood diseases.