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Hailemariam S, Gebeyehu Y, Loha E, Johansson KA, Lindtjørn B. Inadequate management of pneumonia among children in South Ethiopia: findings from descriptive study. BMC Health Serv Res 2019; 19:426. [PMID: 31242946 PMCID: PMC6595689 DOI: 10.1186/s12913-019-4242-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health system support is crucial for quality child healthcare. Therefore, this baseline survey, which is part of the community-based management study of severe pneumonia, was conducted to assess the state of health system support of IMNCI and iCCM, and health workers' knowledge in managing childhood pneumonia at health facilities. METHODS A survey was conducted in 99 government health institutions in South Ethiopia from 07 to 14 January, 2018. A questionnaire for health system support and case scenario for the management of severe pneumonia was adapted from the WHO health facility survey tool. The questionnaire's interview, facility observation, case scenario and retrospective record review were all used as data collection methods. Indicators of health system support in the context of an integrated management of childhood illness were used. Proportions for categorical variables and means for continuous variables were also computed for each indicator. Mean score was analysed for assessing the knowledge of health workers in managing the case scenario. RESULTS In the study area, only 12 (34%) of health centres and 18 (29%) of health posts received supervision, which included the observation of case management. The mean number of essential oral antibiotics for the home treatment of pneumonia available at the facility was 1.1 (95% CI 0.9 to 1.3), whereas the mean number of pre-referral drugs for the treatment of severe pneumonia was 1.3 (95% CI 1.0 to 1.6). Approximately 47 (48%; 95% CI 37.7 to 57.3) of the surveyed health facilities had materials and equipment to support vaccination services, and 71 (72%; 95% CI 62.8 to 80.6) of them had the vaccines on the day of the survey. Only four (4%; 95% CI 0.3 to 8.3) of the health facilities had all the essential job aids and supplies for providing services for pneumonia. The providers' mean knowledge score for the management of severe childhood pneumonia was 14.9 out of 22 correct answers. CONCLUSION There is a room to improve the health system support to integrated management of neonatal and childhood illness through supply chain management and knowledge of health workers in the management of severe pneumonia by providing training.
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Affiliation(s)
- Solomon Hailemariam
- School of Public Health, Dilla University, Dilla, Ethiopia
- School of Public Health, Hawassa University, Hawassa, Ethiopia
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Yabibal Gebeyehu
- Paediatrics Department, School of Medicine, Dilla University, Dilla, Ethiopia
| | - Eskindir Loha
- School of Public Health, Hawassa University, Hawassa, Ethiopia
| | - Kjell Arne Johansson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bernt Lindtjørn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Ndze VN, Jaca A, Wiysonge CS. Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines. Hum Vaccin Immunother 2019; 15:2836-2843. [PMID: 31166843 PMCID: PMC6930115 DOI: 10.1080/21645515.2019.1623998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/07/2019] [Accepted: 04/28/2019] [Indexed: 01/10/2023] Open
Abstract
Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.
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Affiliation(s)
- Valantine Ngum Ndze
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Anelisa Jaca
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Charles Shey Wiysonge
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Rhee C, Aol G, Ouma A, Audi A, Muema S, Auko J, Omore R, Odongo G, Wiegand RE, Montgomery JM, Widdowson MA, O'Reilly CE, Bigogo G, Verani JR. Inappropriate use of antibiotics for childhood diarrhea case management - Kenya, 2009-2016. BMC Public Health 2019; 19:468. [PMID: 32326936 PMCID: PMC6696675 DOI: 10.1186/s12889-019-6771-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Antibiotics are essential to treat for many childhood bacterial infections; however inappropriate antibiotic use contributes to antimicrobial resistance. For childhood diarrhea, empiric antibiotic use is recommended for dysentery (bloody diarrhea) for which first-line therapy is ciprofloxacin. We assessed inappropriate antibiotic prescription for childhood diarrhea in two primary healthcare facilities in Kenya. METHODS We analyzed data from the Kenya Population Based Infectious Disease Surveillance system in Asembo (rural, malaria-endemic) and Kibera (urban slum, non-malaria-endemic). We examined records of children aged 2-59 months with diarrhea (≥3 loose stools in 24 h) presenting for care from August 21, 2009 to May 3, 2016, excluding visits with non-diarrheal indications for antibiotics. We examined the frequency of antibiotic over-prescription (antibiotic prescription for non-dysentery), under-prescription (no antibiotic prescription for dysentery), and inappropriate antibiotic selection (non-recommended antibiotic). We examined factors associated with over-prescription and under-prescription using multivariate logistic regression with generalized estimating equations. RESULTS Of 2808 clinic visits with diarrhea in Asembo, 2685 (95.6%) were non-dysentery visits and antibiotic over-prescription occurred in 52.5%. Of 4697 clinic visits with diarrhea in Kibera, 4518 (96.2%) were non-dysentery and antibiotic over-prescription occurred in 20.0%. Antibiotic under-prescription was noted in 26.8 and 73.7% of dysentery cases in Asembo and Kibera, respectively. Ciprofloxacin was used for 11% of dysentery visits in Asembo and 0% in Kibera. Factors associated with over- and under-prescription varied by site. In Asembo a discharge diagnosis of gastroenteritis was associated with over-prescription (adjusted odds ratio [aOR]:8.23, 95% confidence interval [95%CI]: 3.68-18.4), while malaria diagnosis was negatively associated with antibiotic over-prescription (aOR 0.37, 95%CI: 0.25-0.54) but positively associated with antibiotic under-prescription (aOR: 1.82, 95%CI: 1.05-3.13). In Kibera, over-prescription was more common among visits with concurrent signs of respiratory infection (difficulty breathing; aOR: 3.97, 95%CI: 1.28-12.30, cough: aOR: 1.42, 95%CI: 1.06-1.90) and less common among children aged < 1 year (aOR: 0.82, 95%CI: 0.71-0.94). CONCLUSIONS Inappropriate antibiotic prescription was common in childhood diarrhea management and efforts are needed to promote rational antibiotic use. Interventions to improve antibiotic use for diarrhea should consider the influence of malaria diagnosis on clinical decision-making and address both over-prescription, under-prescription, and inappropriate antibiotic selection.
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Affiliation(s)
- Chulwoo Rhee
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - George Aol
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Alice Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Allan Audi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Shadrack Muema
- Center for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Joshua Auko
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Richard Omore
- Center for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - George Odongo
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ryan E Wiegand
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joel M Montgomery
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Ciara E O'Reilly
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Godfrey Bigogo
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jennifer R Verani
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
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Bessat C, Zonon NA, D'Acremont V. 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. BMC Public Health 2019; 19:449. [PMID: 31035968 PMCID: PMC6489291 DOI: 10.1186/s12889-019-6692-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/21/2019] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Cécile Bessat
- Department of Ambulatory Care and Community Medicine, Lausanne, Switzerland. .,University of Lausanne Medical School, Lausanne, Switzerland.
| | | | - Valérie D'Acremont
- Department of Ambulatory Care and Community Medicine, Lausanne, Switzerland.,Swiss Tropical and Public Health Institute, University of Basel, Lausanne, Switzerland
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Nimpagaritse M, Korachais C, Nsengiyumva G, Macq J, Meessen B. Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi? BMC Nutr 2019; 5:22. [PMID: 32153935 PMCID: PMC7050905 DOI: 10.1186/s40795-019-0282-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 02/15/2019] [Indexed: 12/22/2022] Open
Abstract
Background The Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level. Methods We carried out direct observations of curative outpatient consultations for children aged 6–59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed. Results A total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice. With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2–30.5%) systematically asked the question regarding ‘ongoing breastfeeding’. Only 56 (38.6%)[31–46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6–34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7–22.8%] performed (systematically?) the WHZ-score. More than 50% never gave nutrition advices to any child reviewed. HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding ‘ongoing breastfeeding’ and to perform a ‘weight examination’. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a ‘weight examination’. The ‘height/length’ examination’ was predominantly performed by female HWs and those who have ‘contract with the government. Conclusion This study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country. Trial registration Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).
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Affiliation(s)
- Manassé Nimpagaritse
- Institut National de Santé Publique, Avenue de l'Hôpital n°3/BP, 6807 Bujumbura, Burundi.,2Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.,3Université Catholique de Louvain, Institut de Recherche Santé et Société, Clos Chapelle-aux-Champs, 30 boîte 3016 -1200, Bruxelles, Belgium
| | - Catherine Korachais
- 2Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Georges Nsengiyumva
- Institut National de Santé Publique, Avenue de l'Hôpital n°3/BP, 6807 Bujumbura, Burundi
| | - Jean Macq
- 3Université Catholique de Louvain, Institut de Recherche Santé et Société, Clos Chapelle-aux-Champs, 30 boîte 3016 -1200, Bruxelles, Belgium
| | - Bruno Meessen
- 2Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
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Bernasconi A, Crabbé F, Raab M, Rossi R. Can the use of digital algorithms improve quality care? An example from Afghanistan. PLoS One 2018; 13:e0207233. [PMID: 30475833 PMCID: PMC6261034 DOI: 10.1371/journal.pone.0207233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/27/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Quality of care is a difficult parameter to measure. With the introduction of digital algorithms based on the Integrated Management of Childhood Illness (IMCI), we are interested to understand if the adherence to the guidelines improved for a better quality of care for children under 5 years old. METHODS More than one year after the introduction of digital algorithms, we carried out two cross sectional studies to assess the improvements in comparison with the situation prior to the implementation of the project, in two Basic Health Centres in Kabul province. One survey was carried out inside the consultation room and was based on the direct observation of 181 consultations of children aged 2 months to 5 years old, using a checklist completed by a senior physicians. The second survey queried 181 caretakers of children outside the health facility for their opinion about the consultation carried out through the tablet and prescriptions and medications given. RESULTS We measured the quality of care as adherence to the IMCI's guidelines. The study evaluated the quality of the physical examination and the therapies prescribed with a special attention to antibiotic prescription. We noticed a dramatic improvement (p<0.05) of several indicators following the introduction of digital algorithms. The baseline physical examination was appropriate only for 23.8% [IC% 19.9-28.1] of the patients, 34.5% [IC% 30.0-39.2] received a correct treatment and 86.1% [IC% 82.4-89.2] received at least one antibiotic. With the introduction of digital algorithms, these indicators statistically improved respectively to 84.0% [IC% 77.9-88.6], >85% and less than 30%. CONCLUSIONS Our findings suggest that digital algorithms improve quality of care by applying the guidelines more effectively. Our experience should encourage to test this tool in different settings and to scale up its use at province/state level.
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Affiliation(s)
- Andrea Bernasconi
- Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - François Crabbé
- Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Martin Raab
- Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Rodolfo Rossi
- PHC programs, International Committee of the Red Cross, Genève, Switzerland
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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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Kruk ME, Gage AD, Mbaruku GM, Leslie HH. Content of Care in 15,000 Sick Child Consultations in Nine Lower-Income Countries. Health Serv Res 2018; 53:2084-2098. [PMID: 29516468 PMCID: PMC6052007 DOI: 10.1111/1475-6773.12842] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Describe content of clinical care for sick children in low-resource settings. DATA SOURCES Nationally representative health facility surveys in Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda from 2007 to 2015. STUDY DESIGN Clinical visits by sick children under 5 years were observed and caregivers interviewed. We describe duration and content of the care in the visit and estimate associations between increased content and caregiver knowledge and satisfaction. PRINCIPAL FINDINGS The median duration of 15,444 observations was 8 minutes; providers performed 8.4 of a maximum 24 clinical actions per visit. Content of care was minimally greater for severely ill children. Each additional clinical action was associated with 2 percent higher caregiver knowledge. CONCLUSIONS Consultations for children in nine lower-income countries are brief and limited. A greater number of clinical actions was associated with caregiver knowledge and satisfaction.
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Affiliation(s)
- Margaret E. Kruk
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMA
| | - Anna D. Gage
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMA
| | | | - Hannah H. Leslie
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMA
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Patel S, Zambruni JP, Palazuelos D, Legesse H, Ndiaye NF, Detjen A, Aboubaker S. Rethinking the scale up of Integrated Management of Childhood Illness. BMJ 2018; 362:k2993. [PMID: 30061095 PMCID: PMC6064974 DOI: 10.1136/bmj.k2993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Daniel Palazuelos
- Partners in Health and Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Ndeye Fatou Ndiaye
- United Nations Children's Fund, Middle East and North Africa Regional office, Amman, Jordan
| | - Anne Detjen
- Child Health Unit, United Nations Children's Fund, New York, USA
| | - Samira Aboubaker
- Maternal, Newborn, Child Survival, and Adolescent Health and Development, WHO, Geneva, Switzerland
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Simon JL, Daelmans B, Boschi-Pinto C, Aboubaker S, Were W. Child health guidelines in the era of sustainable development goals. BMJ 2018; 362:bmj.k3151. [PMID: 30061353 PMCID: PMC6081993 DOI: 10.1136/bmj.k3151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Child health guidelines must broaden in scope beyond under 5 mortality to facilitate improvements in child health and development necessary to meet the 2030 sustainable development goals, say Jonathon L Simon and colleagues
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Affiliation(s)
| | | | | | | | - Wilson Were
- World Health Organization, Geneva, Switzerland
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Costello A, Peterson S, Rasanathan K, Daelmans B, Bahl R. Where's the leadership? Future commitments of Unicef and WHO for global child health. BMJ 2018; 362:k3219. [PMID: 30061193 PMCID: PMC6064977 DOI: 10.1136/bmj.k3219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Anthony Costello
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | | | - Bernadette Daelmans
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
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Boschi-Pinto C, Labadie G, Dilip TR, Oliphant N, Dalglish SL, Aboubaker S, Agbodjan-Prince OA, Desta T, Habimana P, Butron-Riveros B, Al-Raiby J, Siddeeg K, Kuttumuratova A, Weber M, Mehta R, Raina N, Daelmans B, Diaz T. Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on. BMJ Open 2018; 8:e019079. [PMID: 30061428 PMCID: PMC6067364 DOI: 10.1136/bmjopen-2017-019079] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/28/2017] [Accepted: 05/01/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. SETTING The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). METHODS We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI's three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. PARTICIPANTS In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. RESULTS Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). CONCLUSION This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.
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Affiliation(s)
- Cynthia Boschi-Pinto
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
- Instituto de Saúde Coletiva, Universidade Federal Fluminense, Niteroi, Brazil
| | - Guilhem Labadie
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | | | - Nicholas Oliphant
- The Global Fund to Fight AIDS, Geneva, Switzerland
- UNICEF, New York, USA
| | - Sarah L Dalglish
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | | | - Teshome Desta
- World Health Organization, Regional Office for East and Southern Africa, Harare, Zimbabwe
| | - Phanuel Habimana
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | | | - Jamela Al-Raiby
- World Health Organization, Regional Office for Eastern Mediterranean, Cairo, Egypt
| | - Khalid Siddeeg
- World Health Organization, Regional Office for Eastern Mediterranean, Cairo, Egypt
| | | | - Martin Weber
- World Health Organization, Regional Office for Europe, Copenhagen, Denmark
| | - Rajesh Mehta
- World Health Organization, Regional Office for South-East Asia, New Delhi, India
| | - Neena Raina
- World Health Organization, Regional Office for South-East Asia, New Delhi, India
| | - Bernadette Daelmans
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
| | - Theresa Diaz
- Department of Maternal Newborn Child and Adolescent Heath, World Health Organization, Geneva, Switzerland
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Muhe LM, Iriya N, Bundala F, Azayo M, Bakari MJ, Hussein A, John T. Evaluation of distance learning IMCI training program: the case of Tanzania. BMC Health Serv Res 2018; 18:547. [PMID: 30001709 PMCID: PMC6044076 DOI: 10.1186/s12913-018-3336-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard 11-days IMCI (Integrated Management of Childhood Illness) training course (standard IMCI) has faced barriers such as high cost to scale up. Distance learning IMCI training program was developed as an alternative to the standard IMCI course. This article presents the evaluation results of the implementation of distance learning IMCI training program in Tanzania. METHODS From December 2012 to end of June 2015, a total of 4806 health care providers (HCP) were trained on distance learning IMCI from 1427 health facilities {HF) in 68 districts in Tanzania. Clinical assessments were done at the end of each course and on follow up visits of health facilities 4 to 6 weeks after training. The results of those assessments are used to compare performance of health care providers trained in distance learning IMCI with those trained in the standard IMCI course. Statistical analysis is done by comparing proportions of those with appropriate performances using four WHO priority performance indicators as well as cost of conducting the courses. In addition, the perspectives of health care providers, IMCI course facilitators, policy makers and partners were gathered using either focussed group discussions or structured questionnaires. RESULTS Distance learning IMCI allowed clusters of training courses to take place in parallel, allowing rapid expansion of IMCI coverage. Health care providers trained in distance learning IMCI performed equally well as those trained in the standard IMCI course in assessing Main Symptoms, treating sick children and counselling caretakers appropriately. They performed better in assessing Danger Signs. Distance learning IMCI gave a 70% reduction in cost of conducting the training courses. CONCLUSION Distance learning IMCI is an alternative to scaling up IMCI as it provides an effective option with significant cost reduction in conducting training courses.
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Affiliation(s)
- Lulu M Muhe
- Department of Pediatrics and Child Health, Addis Ababa University, P.O.Box 1768, Addis Ababa, Ethiopia.
| | - Nemes Iriya
- Child and Adolescent Health, World Health Organization Country Office, Dar Es Salaam, Tanzania
| | | | - Mary Azayo
- UNICEF Country Office, Dar Es Salaam, Tanzania
| | | | | | - Theopista John
- Child and Adolescent Health, World Health Organization Country Office, Dar Es Salaam, Tanzania
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Electronic clinical decision algorithms for the integrated primary care management of febrile children in low-resource settings: review of existing tools. Clin Microbiol Infect 2018; 24:845-855. [PMID: 29684634 DOI: 10.1016/j.cmi.2018.04.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The lack of effective, integrated diagnostic tools poses a major challenge to the primary care management of febrile childhood illnesses. These limitations are especially evident in low-resource settings and are often inappropriately compensated by antimicrobial overprescription. Electronic clinical decision algorithms (eCDAs) have the potential to close these gaps by guiding antibiotic use and better identifying serious disease. AIMS This narrative review summarizes existing eCDAs, to provide an overview of their degree of validation and to identify gaps in current knowledge and prospects for future innovation. SOURCES Structured literature review in PubMed and Embase complemented by Google search and contact with developers. CONTENT Six integrated eCDAs were identified: three (eIMCI, REC and Bangladesh digital IMCI) based on Integrated Management of Childhood Illnesses (IMCI); four (SL electronic iCCM, MEDSINC, electronic iCCM and D-Tree electronic iCCM) on Integrated Community Case Management (iCCM); two (ALMANACH, MSFeCARE) with a modified IMCI content; and one (ePOCT) that integrates novel content with biomarker testing. The types of publications and evaluation studies varied greatly: the content and evidence base were published for two (ALMANACH and ePOCT) and ALMANACH and ePOCT were validated in efficacy studies. Other types of evaluations, such as compliance and acceptability, were available for D-Tree electronic iCCM, eIMCI and ALMANACH. Several evaluations are still ongoing. Future prospects include conducting effectiveness and impact studies using data gathered through larger studies to adapt the medical content to local epidemiology, improving the software and sensors, and assessing factors that influence compliance and scale-up. IMPLICATIONS eCDAs are valuable tools that have the potential to improve management of febrile children in primary care and increase the rational use of diagnostics and antimicrobials. Next steps in the evidence pathway should be larger effectiveness and impact studies (including cost analysis) and continuous integration of clinically useful diagnostic and treatment innovations.
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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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Update on Prevention Efforts for Pneumonia Attributed Deaths in Children Under 5 Years of Age. CURRENT TROPICAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40475-018-0138-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Damien BG, Aguemon B, Abdoulaye Alfa D, Bocossa D, Ogouyemi-Hounto A, Remoue F, Le Hesran JY. Low use of artemisinin-based combination therapy for febrile children under five and barriers to correct fever management in Benin: a decade after WHO recommendation. BMC Public Health 2018; 18:168. [PMID: 29357869 PMCID: PMC5778640 DOI: 10.1186/s12889-018-5077-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 01/12/2018] [Indexed: 11/16/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT), used to treat uncomplicated malaria cases, is one of the main strategies of malaria control and elimination. One of the main objectives of the Benin National Malaria Control Program’s (NMCP) strategic plan is to ensure that at least 80% of uncomplicated malaria is treated with ACT within 24 h. Therefore, it was of great interest to measure whether the country case management of fever amongst children under five, adhered to the NMCP’s strategic plan and look into the barriers to the use of ACT. Methods A cross-sectional survey based on a cluster and multi-stage sampling was conducted in two rural health districts in Benin. We recruited 768 and 594 children under five years were included in the northern and in the southern respectively. Data was collected on the general use of ACT and on the correct use of ACT that adheres to the NMCP’s strategy, as well as the barriers that prevent the proper management of fever amongst children. To assess the certain predictors of ACT usage, logistic regression was used, while taking into account the cluster random effect. Results Among febrile children aged 6 to 59 months, 20.7% in the south and 33.9% in north received ACT. The correct use of ACT, was very low, 5.8% and in southern and 8.6% northern areas. Caregivers who received information on ACT were 3.13 time more likely in the south and 2.98 time more likely in the north to give ACT to their feverish child, PPR = 3.13[1.72–4.15] and PPR = 2.98 [2.72–3.11] respectively. Chloroquine and quinine, other malaria treatments not recommended by NMCP, were still being used in both areas: 12.3 and 3.3% in the south and 11.4 and 3.0% in the north. Conclusion In Benin, the use and the correct use of ACT for febrile children remains low. The study also showed that having received information about the use of ACT is positively associated with the use of ACT. This point highlights the fact that efforts may not have been sufficiently integrated with social communication, which should be based on the behavioural determinants of populations. Electronic supplementary material The online version of this article (10.1186/s12889-018-5077-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- B G Damien
- Institut de Recherche pour le Développement (IRD), Maladies Infectieuses et Vecteurs: Ecologie, Génétique, Evolution et Contrôle (MIVEGEC), UMR IRD 224-CNRS 5290, University of Montpellier, Montpellier, France. .,Centre de Recherche Entomologique de Cotonou, Bénin / Institut de Recherche pour le Développement, UMR 224-CNRS 5290 MIVEGEC, Cotonou, Bénin. .,Département de Santé Publique, Faculté des Sciences de la Santé de Cotonou, Université d'Abomey-Calavi, Cotonou, Bénin.
| | - B Aguemon
- Département de Santé Publique, Faculté des Sciences de la Santé de Cotonou, Université d'Abomey-Calavi, Cotonou, Bénin
| | - D Abdoulaye Alfa
- Centre de Recherche Entomologique de Cotonou, Bénin / Institut de Recherche pour le Développement, UMR 224-CNRS 5290 MIVEGEC, Cotonou, Bénin
| | - D Bocossa
- Université Paris 8, UFR Etudes - Recherche - et Ingénierie en territoires - Environnements - Société, Saint-Denis, France
| | - A Ogouyemi-Hounto
- Unité d'Enseignement et de Recherche en Parasitologie Mycologie/Faculté des Sciences de la Santé, Laboratoire du Centre de Lutte Intégrée contre le Paludisme, Université d'Abomey-Calavi, Cotonou, Bénin
| | - F Remoue
- Institut de Recherche pour le Développement (IRD), Maladies Infectieuses et Vecteurs: Ecologie, Génétique, Evolution et Contrôle (MIVEGEC), UMR IRD 224-CNRS 5290, University of Montpellier, Montpellier, France.,Centre de Recherche Entomologique de Cotonou, Bénin / Institut de Recherche pour le Développement, UMR 224-CNRS 5290 MIVEGEC, Cotonou, Bénin
| | - J-Y Le Hesran
- Institut de Recherche pour le Développement (IRD) / Mère et enfant face aux infections tropicales (MERIT), UMR 216, Cotonou, Bénin
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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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Oliphant NP, Daniels K, Odendaal WA, Besada D, Manda S, Kinney M, White Johansson E, Lunze K, Johansen M, Doherty T. Integrated community case management of childhood illness in low- and middle-income countries. Hippokratia 2017. [DOI: 10.1002/14651858.cd012882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nicholas P Oliphant
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria; Program Division, LAC; Chemin de Blandonnet 8 Vernier Geneva Switzerland 1214
- University of the Western Cape; School of Public Health; Robert Sobukwe Road Cape Town South Africa 7535
| | - Karen Daniels
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
- University of Cape Town; Health Policy and Systems Division, School of Public Health and Family Medicine; Observatory, Cape Town Western Cape South Africa 7925
| | - Willem A Odendaal
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
| | - Donela Besada
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
| | - Samuel Manda
- South African Medical Research Council; Biostatistics Unit; Pretoria South Africa
- School of Public Health, University of Witwatersrand; Division of Epidemiology and Biostatistics; Johannesburg South Africa
| | - Mary Kinney
- Save the Children; Global Health and Nutrition; Edgemead Western Cape South Africa 7441
| | - Emily White Johansson
- Uppsala Universitet; International Maternal and Child Health, Department of Womens and Childrens Health; SE-751 85 Sweden Uppsala
| | - Karsten Lunze
- Boston University, School of Medicine; Department of Medicine; Boston Massachusetts USA 02118
| | - Marit Johansen
- Norwegian Institute of Public Health; Department for Evidence Synthesis; Pilestredet Park 7 Oslo Norway N-0130
| | - Tanya Doherty
- University of the Western Cape; School of Public Health; Robert Sobukwe Road Cape Town South Africa 7535
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
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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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Keitel K, Kagoro F, Samaka J, Masimba J, Said Z, Temba H, Mlaganile T, Sangu W, Rambaud-Althaus C, Gervaix A, Genton B, D’Acremont V. A novel electronic algorithm using host biomarker point-of-care tests for the management of febrile illnesses in Tanzanian children (e-POCT): A randomized, controlled non-inferiority trial. PLoS Med 2017; 14:e1002411. [PMID: 29059253 PMCID: PMC5653205 DOI: 10.1371/journal.pmed.1002411] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/19/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The management of childhood infections remains inadequate in resource-limited countries, resulting in high mortality and irrational use of antimicrobials. Current disease management tools, such as the Integrated Management of Childhood Illness (IMCI) algorithm, rely solely on clinical signs and have not made use of available point-of-care tests (POCTs) that can help to identify children with severe infections and children in need of antibiotic treatment. e-POCT is a novel electronic algorithm based on current evidence; it guides clinicians through the entire consultation and recommends treatment based on a few clinical signs and POCT results, some performed in all patients (malaria rapid diagnostic test, hemoglobin, oximeter) and others in selected subgroups only (C-reactive protein, procalcitonin, glucometer). The objective of this trial was to determine whether the clinical outcome of febrile children managed by the e-POCT tool was non-inferior to that of febrile children managed by a validated electronic algorithm derived from IMCI (ALMANACH), while reducing the proportion with antibiotic prescription. METHODS AND FINDINGS We performed a randomized (at patient level, blocks of 4), controlled non-inferiority study among children aged 2-59 months presenting with acute febrile illness to 9 outpatient clinics in Dar es Salaam, Tanzania. In parallel, routine care was documented in 2 health centers. The primary outcome was the proportion of clinical failures (development of severe symptoms, clinical pneumonia on/after day 3, or persistent symptoms at day 7) by day 7 of follow-up. Non-inferiority would be declared if the proportion of clinical failures with e-POCT was no worse than the proportion of clinical failures with ALMANACH, within statistical variability, by a margin of 3%. The secondary outcomes included the proportion with antibiotics prescribed on day 0, primary referrals, and severe adverse events by day 30 (secondary hospitalizations and deaths). We enrolled 3,192 patients between December 2014 and February 2016 into the randomized study; 3,169 patients (e-POCT: 1,586; control [ALMANACH]: 1,583) completed the intervention and day 7 follow-up. Using e-POCT, in the per-protocol population, the absolute proportion of clinical failures was 2.3% (37/1,586), as compared with 4.1% (65/1,583) in the ALMANACH arm (risk difference of clinical failure -1.7, 95% CI -3.0, -0.5), meeting the prespecified criterion for non-inferiority. In a non-prespecified superiority analysis, we observed a 43% reduction in the relative risk of clinical failure when using e-POCT compared to ALMANACH (risk ratio [RR] 0.57, 95% CI 0.38, 0.85, p = 0.005). The proportion of severe adverse events was 0.6% in the e-POCT arm compared with 1.5% in the ALMANACH arm (RR 0.42, 95% CI 0.20, 0.87, p = 0.02). The proportion of antibiotic prescriptions was substantially lower, 11.5% compared to 29.7% (RR 0.39, 95% CI 0.33, 0.45, p < 0.001). Using e-POCT, the most common indication for antibiotic prescription was severe disease (57%, 103/182 prescriptions), while it was non-severe respiratory infections using the control algorithm (ALMANACH) (70%, 330/470 prescriptions). The proportion of clinical failures among the 544 children in the routine care cohort was 4.6% (25/544); 94.9% (516/544) of patients received antibiotics on day 0, and 1.1% (6/544) experienced severe adverse events. e-POCT achieved a 49% reduction in the relative risk of clinical failure compared to routine care (RR 0.51, 95% CI 0.31, 0.84, p = 0.007) and lowered antibiotic prescriptions to 11.5% from 94.9% (p < 0.001). Though this safety study was an important first step to evaluate e-POCT, its true utility should be evaluated through future implementation studies since adherence to the algorithm will be an important factor in making use of e-POCT's advantages in terms of clinical outcome and antibiotic prescription. CONCLUSIONS e-POCT, an innovative electronic algorithm using host biomarker POCTs, including C-reactive protein and procalcitonin, has the potential to improve the clinical outcome of children with febrile illnesses while reducing antibiotic use through improved identification of children with severe infections, and better targeting of children in need of antibiotic prescription. TRIAL REGISTRATION ClinicalTrials.gov NCT02225769.
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Affiliation(s)
- Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Lausanne, Switzerland
- * E-mail:
| | - Frank Kagoro
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Josephine Samaka
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Amana Hospital, Dar es Salaam, Tanzania
| | - John Masimba
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Zamzam Said
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | | | | | - Alain Gervaix
- Pediatric Emergency Medicine Department, Child and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Lausanne, Switzerland
- Infectious Diseases Service, University Hospital Lausanne, Lausanne, Switzerland
| | - Valérie D’Acremont
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Lausanne, Switzerland
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Tadesse BT, Ashley EA, Ongarello S, Havumaki J, Wijegoonewardena M, González IJ, Dittrich S. Antimicrobial resistance in Africa: a systematic review. BMC Infect Dis 2017; 17:616. [PMID: 28893183 PMCID: PMC5594539 DOI: 10.1186/s12879-017-2713-1] [Citation(s) in RCA: 255] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 09/04/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is widely acknowledged as a global problem, yet in many parts of the world its magnitude is still not well understood. This review, using a public health focused approach, aimed to understand and describe the current status of AMR in Africa in relation to common causes of infections and drugs recommended in WHO treatment guidelines. METHODS PubMed, EMBASE and other relevant databases were searched for recent articles (2013-2016) in accordance with the PRISMA guidelines. Article retrieval and screening were done using a structured search string and strict inclusion/exclusion criteria. Median and interquartile ranges of percent resistance were calculated for each antibiotic-bacterium combination. RESULTS AMR data was not available for 42.6% of the countries in the African continent. A total of 144 articles were included in the final analysis. 13 Gram negative and 5 Gram positive bacteria were tested against 37 different antibiotics. Penicillin resistance in Streptococcus pneumoniae was reported in 14/144studies (median resistance (MR): 26.7%). Further 18/53 (34.0%) of Haemophilus influenza isolates were resistant to amoxicillin. MR of Escherichia coli to amoxicillin, trimethoprim and gentamicin was 88.1%, 80.7% and 29.8% respectively. Ciprofloxacin resistance in Salmonella Typhi was rare. No documented ceftriaxone resistance in Neisseria gonorrhoeae was reported, while the MR for quinolone was 37.5%. Carbapenem resistance was common in Acinetobacter spp. and Pseudomonas aeruginosa but uncommon in Enterobacteriaceae. CONCLUSION Our review highlights three important findings. First, recent AMR data is not available for more than 40% of the countries. Second, the level of resistance to commonly prescribed antibiotics was significant. Third, the quality of microbiological data is of serious concern. Our findings underline that to conserve our current arsenal of antibiotics it is imperative to address the gaps in AMR diagnostic standardization and reporting and use available information to optimize treatment guidelines.
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Affiliation(s)
- Birkneh Tilahun Tadesse
- 0000 0001 1507 3147grid.452485.aFoundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland ,0000 0000 8953 2273grid.192268.6College of Medicine and Health Sciences, Department of Pediatrics, Hawassa University, Hawassa, Ethiopia ,grid.463322.2Special Programme for Research & Training in Tropical Diseases (TDR), World Health Organization, Avenue Appia 20, 1211, 27 Geneva, Switzerland
| | | | - Stefano Ongarello
- 0000 0001 1507 3147grid.452485.aFoundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Joshua Havumaki
- 0000 0001 1507 3147grid.452485.aFoundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Miranga Wijegoonewardena
- 0000 0001 1507 3147grid.452485.aFoundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Iveth J. González
- 0000 0001 1507 3147grid.452485.aFoundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Sabine Dittrich
- 0000 0001 1507 3147grid.452485.aFoundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland
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Kobayashi M, Mwandama D, Nsona H, Namuyinga RJ, Shah MP, Bauleni A, Vanden Eng JV, Rowe AK, Mathanga DP, Steinhardt LC. Quality of Case Management for Pneumonia and Diarrhea Among Children Seen at Health Facilities in Southern Malawi. Am J Trop Med Hyg 2017; 96:1107-1116. [PMID: 28500813 DOI: 10.4269/ajtmh.16-0945] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pneumonia and diarrhea are leading causes of child deaths in Malawi. Guidelines to manage childhood illnesses in resource-poor settings exist, but studies have reported low health-care worker (HCW) adherence to guidelines. We conducted a health facility survey from January to March 2015 to assess HCW management of pneumonia and diarrhea in children < 5 years of age in southern Malawi, and to determine factors associated with case management quality. Descriptive statistics and multivariable logistic regression models examined patient, HCW, and health facility factors associated with recommended pneumonia and diarrhea management, using Malawi's national guidelines as the gold standard. Of 694 surveyed children 2-59 months of age at 95 health facilities, 132 (19.0%) met survey criteria for pneumonia; HCWs gave recommended antibiotic treatment to 90 (68.2%). Of 723 children < 5 years of age, 222 (30.7%) had uncomplicated diarrhea; HCWs provided recommended treatment to 94 (42.3%). In multivariable analyses, caregivers' spontaneous report of children's symptoms was associated with recommended treatment of both pneumonia (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.2-6.8, P = 0.023) and diarrhea (OR: 24.2, 95% CI: 6.0-97.0, P < 0001). Malaria diagnosis was negatively associated with recommended treatment (OR for pneumonia: 0.5, 95% CI: 0.2-1.0, P = 0.046; OR for diarrhea: 0.3, 95% CI: 0.1-0.6, P = 0.003). To improve quality of care, children should be assessed systematically, even when malaria is suspected. Renewed efforts to invigorate such a systematic approach, including HCW training, regular follow-up supervision, and monitoring HCW performance, are needed in Malawi.
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Affiliation(s)
- Miwako Kobayashi
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.,Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dyson Mwandama
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Ruth J Namuyinga
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia.,Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica P Shah
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andrew Bauleni
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jodi Vanden Vanden Eng
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander K Rowe
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Don P Mathanga
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laura C Steinhardt
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Awasthi S. Improving management of dehydration in children younger than 5 years in low-and-middle-income countries. THE LANCET GLOBAL HEALTH 2016; 4:e674-5. [DOI: 10.1016/s2214-109x(16)30179-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 01/15/2023] Open
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