An Evaluation of the Quality of IMCI Assessments among IMCI Trained Health Workers in South Africa

Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa.
PLoS ONE (Impact Factor: 3.23). 02/2009; 4(6):e5937. DOI: 10.1371/journal.pone.0005937
Source: PubMed


Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa.
Seventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW's had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children.
Health workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.

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    • "Among health workers with IMCI training, the quality of care was better with at least one supervision visit every six months in Uganda [14), and with study supports including supervision in Benin (19]. Horwood et al. (2009) recommended further research on the role of supervision to maintain IMCI skills and on different models of supervision [20]. The Joint Uganda Malaria Training Program (JUMP) combined classroom sessions, practice and supervision visits, and was effective at improving case management of fever among children [21]. "
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    ABSTRACT: Background: The Integrated Infectious Disease Capacity-Building Evaluation (IDCAP) was designed to test the effects of two interventions, Integrated Management of Infectious Disease (IMID) training and on-site support (OSS), on clinical practice of mid-level practitioners. This article reports the effects of these interventions on clinical practice in management of common childhood illnesses. Methods: Two trainees from each of 36 health facilities participated in the IMID training. IMID was a three-week core course, two one-week boost courses, and distance learning over nine months. Eighteen of the 36 health facilities were then randomly assigned to arm A, and participated in OSS, while the other 18 health facilities assigned to arm B did not. Clinical faculty assessed trainee practice on clinical practice of six sets of tasks: patient history, physical examination, laboratory tests, diagnosis, treatment, and patient/caregiver education. The effects of IMID were measured by the post/pre adjusted relative risk (aRR) of appropriate practice in arm B. The incremental effects of OSS were measured by the adjusted ratio of relative risks (aRRR) in arm A compared to arm B. All hypotheses were tested at a 5 % level of significance. Results: Patient samples were comparable across arms at baseline and endline. The majority of children were aged under five years; 84 % at baseline and 97 % at endline. The effects of IMID on patient history (aRR = 1.12; 95 % CI = 1.04-1.21) and physical examination (aRR = 1.40; 95 % CI = 1.16-1.68) tasks were statistically significant. OSS was associated with incremental improvement in patient history (aRRR = 1.18; 95 % CI = 1.06-1.31), and physical examination (aRRR = 1.27; 95 % CI = 1.02-1.59) tasks. Improvements in laboratory testing, diagnosis, treatment, and patient/caregiver education were not statistically significant. Conclusion: IMID training was associated with improved patient history taking and physical examination, and OSS further improved these clinical practices. On-site training and continuous quality improvement activities support transfer of learning to practice among mid-level practitioners.
    Full-text · Article · Aug 2015 · BMC Pediatrics
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    • "Poor systems of supervision and follow-up may be one reason why clinicians do not acknowledge the importance of the IMCI tool. There is ample evidence to show that training alone does not secure adherence to IMCI, that systems to reinforce guidelines over time are needed and that supervision does indeed have an effect in many cases (Anatole et al., 2013; Horwood et al., 2009: 5; Osterholt, Onikpo, Lama, Deming, & Rowe, 2009; Rowe, 2009; Rowe, de Savigny, Lanata, & Victora, 2005; Rowe et al., 2012). The multicountry evaluation of IMCI found that supervision systems were not sustained in any of the countries (Bryce et al., 2005). "
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    ABSTRACT: The Integrated Management of Childhood Illness (IMCI) has been introduced to reduce child morbidity and mortality in countries with a poor health infrastructure. Previous studies have documented a poor adherence to clinical guidelines, but little is known about the reasons for non-adherence. This mixed-method study measures adherence to IMCI case-assessment guidelines and identifies the reasons for weak adherence. In 2007, adherence was measured through direct observation of 933 outpatient consultations performed by 103 trained clinicians in 82 health facilities in nine districts in rural Tanzania, while clinicians' knowledge of the guidelines was assessed through clinical vignettes. Other potential reasons for a weak adherence were assessed through both a health worker- and health facility survey, as well as by a qualitative follow-up study in 2009 in which in-depth interviews were conducted with 40 clinicians in 30 health facilities located in two of the same districts. Clinicians performed 28.4% of the relevant IMCI assessment tasks. The level of knowledge was considerably higher than actual performance, suggesting that lack of knowledge is not the only constraint for improved performance. Other important reasons for weak performance seem to be 1) lack of motivation to adhere to IMCI guidelines, stemming partly from a weak belief in the importance of following the guidelines and partly from weak intrinsic motivation, and 2) a physical and/or cognitive "overload", resulting in lack of capacity to concentrate fully on each and every case and a resort to simpler rules of thumb. Poor remunerations contribute to several of these factors.
    Full-text · Article · Mar 2014 · Social Science [?] Medicine
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    • "A study in Bangladesh highlighted the potential for incomplete assessments, and incorrect treatment amongst IMCI trained providers [18]. The reinforcement of training and provision of supportive supervision were factors that different studies identified as contributing to health workers performance in relation to IMCI [19,20]. "
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    ABSTRACT: Background Quality hospital care is important in ensuring that the needs of severely ill children are met to avert child mortality. However, the quality of hospital care for children in developing countries has often been found poor. As the first step of a country road map for improving hospital care for children, we assessed the baseline situation with respect to the quality of care provided to children under-five years age in district and sub-district level hospitals in Bangladesh. Methods Using adapted World Health Organization (WHO) hospital assessment tools and standards, an assessment of 18 randomly selected district (n=6) and sub-district (n=12) hospitals was undertaken. Teams of trained assessors used direct case observation, record review, interviews, and Management Information System (MIS) data to assess the quality of clinical case management and monitoring; infrastructure, processes and hospital administration; essential hospital and laboratory supports, drugs and equipment. Results Findings demonstrate that the overall quality of care provided in these hospitals was poor. No hospital had a functioning triage system to prioritise those children most in need of immediate care. Laboratory supports and essential equipment were deficient. Only one hospital had all of the essential drugs for paediatric care. Less than a third of hospitals had a back-up power supply, and just under half had functioning arrangements for safe-drinking water. Clinical case management was found to be sub-optimal for prevalent illnesses, as was the quality of neonatal care. Conclusion Action is needed to improve the quality of paediatric care in hospital settings in Bangladesh, with a particular need to invest in improving newborn care.
    Full-text · Article · Dec 2012 · BMC Pediatrics
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