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

The Tools for Integrated Management of Childhood Illness (TIMCI) study protocol: a multi-country mixed-method evaluation of pulse oximetry and clinical decision support algorithms

Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up.Study registration: NCT04910750 and NCT05065320.

The effects of climatic and non-climatic factors on malaria mortality at different spatial scales in western Kenya, 2008-2019

BACKGROUND

Malaria mortality is influenced by several factors including climatic and environmental factors, interventions, socioeconomic status (SES) and access to health systems. Here, we investigated the joint effects of climatic and non-climatic factors on under-five malaria mortality at different spatial scales using data from a Health and Demographic Surveillance System (HDSS) in western Kenya.

METHODS

We fitted Bayesian spatiotemporal (zero-inflated) negative binomial models to monthly mortality data aggregated at the village scale and over the catchment areas of the health facilities within the HDSS, between 2008 and 2019. First order autoregressive temporal and conditional autoregressive spatial processes were included as random effects to account for temporal and spatial variation. Remotely sensed climatic and environmental variables, bed net use, SES, travel time to health facilities, proximity from water bodies/streams and altitude were included in the models to assess their association with malaria mortality.

RESULTS

Increase in rainfall (mortality rate ratio (MRR)=1.12, 95% Bayesian credible interval (BCI): 1.04-1.20), Normalized Difference Vegetation Index (MRR=1.16, 95% BCI: 1.06-1.28), crop cover (MRR=1.17, 95% BCI: 1.11-1.24) and travel time to the hospital (MRR=1.09, 95% BCI: 1.04-1.13) were associated with increased mortality, whereas increase in bed net use (MRR=0.84, 95% BCI: 0.70-1.00), distance to the nearest streams (MRR=0.89, 95% BCI: 0.83-0.96), SES (MRR=0.95, 95% BCI: 0.91-1.00) and altitude (MRR=0.86, 95% BCI: 0.81-0.90) were associated with lower mortality. The effects of travel time and SES were no longer significant when data was aggregated at the health facility catchment level.

CONCLUSION

Despite the relatively small size of the HDSS, there was spatial variation in malaria mortality that peaked every May-June. The rapid decline in malaria mortality was associated with bed nets, and finer spatial scale analysis identified additional important variables. Time and spatially targeted control interventions may be helpful, and fine spatial scales should be considered when data are available.

Implementation of the WHO standards to assess the quality of care for children with acute diarrhoea: findings of a multicentre study (CHOICE) in Italy

BACKGROUND

There is no documented experience in the use of the WHO standards for improving the quality of care (QOC) for children at the facility level. We describe the use of 10 prioritised WHO-Standard-based Quality Measures to assess QOC for children with acute diarrhoea (AD) in Italy.

METHODS

In a multicentre observational study in 11 paediatric emergency departments with different characteristics and geographical location, we collected data on 3061 children aged 6 months to 15 years with AD and no complications. Univariate and multivariate analyses were conducted.

RESULTS

Study findings highlighted both good practices and gaps in QoC, with major differences in QOC across facilities. Documentation of body weight and temperature varied from 7.7% to 98.5% and from 50% to 97.7%, respectively (p<0.001); antibiotic and probiotic prescription rates ranged from 0% to 10.1% and from 0% to 80.8%, respectively (p<0.001); hospitalisations rates ranged between 8.5% and 62.8% (p<0.001); written indications for reassessment were provided in 10.4%-90.2% of cases (p<0.001). When corrected for children's individual characteristics, the variable more consistently associated with each analysed outcome was the individual facility. Higher rates of antibiotics prescription (+7.6%, p=0.04) and hospitalisation (+52.9%, p<0.001) were observed for facilities in Southern Italy, compared with university centres (-36%, p<0.001), independently from children characteristics. Children's clinical characteristics in each centre were not associated with either hospitalisation or antibiotic prescription rates.

CONCLUSIONS

The 10 prioritised WHO-Standard-based Quality Measures allow a rapid assessment of QOC in children with AD. Action is needed to identify and implement sustainable and effective interventions to ensure high QOC for all children.

Utilization of the Integrated Management of Newborn and Childhood Illness (IMNCI) protocol and associated factors among health care workers in health centers of South Gondar Zone, Northwest Ethiopia: an institution-based mixed study

Introduction

Globally, 11 million children have died before reaching their fifth birthday. The introduction of the Integrated Management of Newborn and Childhood Illness (IMNCI) protocol reduces the morbidity and mortality rates among children under the age of 5. However, the share of neonatal mortality is increasing. As a result, the United Nations has established sustainable development goals to reduce national neonatal death rates through the utilization of the Integrated Management of Newborn and Childhood Illness protocol as the main tool for 12 per 1,000 live births by 2030. However, the death rate from preventable causes has increased owing to the low utilization of the protocol.

Objective

The objective of this research is to assess the utilization of the IMNCI protocol and associated factors among healthcare workers (HCW) in health centers at the South Gondar Zone, Northwest Ethiopia, in 2022.

Methods

The institution-based mixed study design was conducted from November to December 2022 at the South Gondar Zone, Amhara. A total of 422 HCW were selected using a computer-generated random-number generator. Data were cleaned and entered into EpiData 3.1 software and analyzed using SPSS version 25.0. Binary logistic regression was used to identify candidates for multivariable logistic analysis with p-value < 0.2, and for multivariable analysis, p-value < 0.05, with a 95% confidence interval, was considered significant. Thematic analysis was used for the qualitative data.

Results

In total, 417 respondents were included in the final analysis. The overall response rate was 98.8%, and the mean age was 30.01 years. The results showed that the proportion of IMNCI utilization was 63.1%. The odds of the utilization of IMNCI protocol among HCW who took training were 3.13 times higher than those among HCW who did not take training [adjusted odds ratio (AOR) = 3.13, 95% CI: 1.594, 6.147]. The lack of drugs reduces the utilization of the IMNCI protocol by 75.7% compared with the use of drugs (AOR = 0.243, CI: 95%:0.128, 0.464). HCW who always referred to the chart booklet during case management were 3.34 times more likely to utilize the IMNCI protocol (AOR = 3.34, 95% CI: 1.99, 5.60) compared with those who did not refer to the chart booklet.

Conclusions and recommendations

The utilization of the IMNCI protocol was low. A shortage of medical consumables and equipment attitude and training were identified as factors that affected the utilization of the protocol. Therefore, the availability of necessary logistics and training for employees with regular supportive supervision and monitoring should be conducted with the integration of sectors at the district and zone levels.

Digitalizing Clinical Guidelines: Experiences in the Development of Clinical Decision Support Algorithms for Management of Childhood Illness in Resource-Constrained Settings

Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interpretation when translating narrative guidelines into decision logic combined with considerations of context and design choices. Between October 2019 and April 2021, we conducted a comparative analysis of 4 IMCI-related CDSSs. The extent of adaptations to IMCI varied, but common themes emerged. Scope was extended to cover a broader range of conditions. Content was added or modified to enhance precision, align with new evidence, and support rational resource use. Structure was modified to increase efficiency, improve usability, and prioritize care for severely ill children. The multistakeholder development processes involved syntheses of recommendations from existing guidelines and literature; creation and validation of clinical algorithms; and iterative development, implementation, and evaluation. The common themes surrounding adaptations of IMCI guidance highlight the complexities of digitalizing evidence-based recommendations and reinforce the rationale for leveraging standards for CDSS development, such as the World Health Organization's SMART Guidelines. Implementation through multistakeholder dialogue is critical to ensure CDSSs can effectively and equitably improve quality of care for children in resource-constrained settings.

Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals

Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.

Quality of sick child management by health extension workers: role of a complex improvement intervention

BACKGROUND

Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers.

METHODS

The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses.

RESULTS

We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention.

CONCLUSION

The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities.

TRIAL REGISTRATION NUMBER

ISRCTN12040912, retrospectively registered on 19/12/ 2017.

Antibiotic Prescription Patterns in Children Under 5 Years of Age With Acute Diarrhea in Quito-Ecuador

BACKGROUND

Diarrheal disease remains a significant cause of child mortality, particularly in regions with limited access to healthcare and sanitation. Inappropriate practices, including unjustified medication prescriptions, pose challenges in the management of acute diarrhea (AD), especially in low- and middle-income countries.

OBJECTIVE

This study analyzed antibiotic prescription patterns and assessed compliance with Integrated Management of Childhood Illness (IMCI) guidelines in children under 5 with AD in the Ministry of Public Health (MOPH) Ambulatory Care Centers of Quito city, Ecuador.

METHODS

A cross-sectional design was used, collecting electronic health records (EHR) of patients diagnosed with AD from 21 health facilities in District 17D03. A probabilistic and stratified sampling approach was applied. Patient characteristics, prescriber characteristics, treatments, and compliance of IMCI guideline recommendations were evaluated. A stepwise logistic regression analysis examined the association between antibiotic prescription and patient and physician characteristics.

RESULTS

A total of 359 children under 5 years of age were included, with 58.77% being girls. 85.24% of the cases of AD were attributed to gastroenteritis and colitis of infectious and unspecified origin. Amebiasis and other protozoal intestinal diseases accounted for 13.37% and 1.11% of the cases, respectively. The completion rates of recording various IMCI parameters varied; parameters such as duration of diarrhea, presence of blood in stool, and evidence of sunken eyes had high completion rates (100%, 100%, and 87.47%, respectively), while parameters like state of consciousness, presence of thirst, and type of diarrhea had low completion rates (0.28%, 0.28%, and 0.84%, respectively). None of the cases had all parameters fully recorded. Antimicrobials were prescribed in 38.72% of the cases. Children aged 3 to 5 years had higher odds of receiving antimicrobial prescription for AD (aOR: 4.42, 95% CI 2.13-9.18, P < .0001) compared to those under 1 year, after adjusting for the number of loose stools per day, gender, and age of the health professional.

CONCLUSION

Variations in IMCI guideline compliance were observed, with no cases fully adhering to the guidelines. Antimicrobial prescription rates were notably high, especially among older children. Further research and specialized interventions are necessary to gain comprehensive insight into the factors underlying non-compliance with the IMCI guidelines.

Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries

Background

WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any "general danger sign" can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so.

Methods

We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries.

Results

We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review.

Conclusions

Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.

Effectiveness of an electronic clinical decision support system in improving the management of childhood illness in primary care in rural Nigeria: an observational study

OBJECTIVES

To evaluate the impact of ALgorithm for the MANAgement of CHildhood illness ('ALMANACH'), a digital clinical decision support system (CDSS) based on the Integrated Management of Childhood Illness, on health and quality of care outcomes for sick children attending primary healthcare (PHC) facilities.

DESIGN

Observational study, comparing outcomes of children attending facilities implementing ALMANACH with control facilities not yet implementing ALMANACH.

SETTING

PHC facilities in Adamawa State, North-Eastern Nigeria.

PARTICIPANTS

Children 2-59 months presenting with an acute illness. Children attending for routine care or nutrition visits (eg, immunisation, growth monitoring), physical trauma or mental health problems were excluded.

INTERVENTIONS

The ALMANACH intervention package (CDSS implementation with training, mentorship and data feedback) was rolled out across Adamawa's PHC facilities by the Adamawa State Primary Health Care Development Agency, in partnership with the International Committee of the Red Cross and the Swiss Tropical and Public Health Institute. Tablets were donated, but no additional support or incentives were provided. Intervention and control facilities received supportive supervision based on the national supervision protocol.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was caregiver-reported recovery at day 7, collected over the phone. Secondary outcomes were antibiotic and antimalarial prescription, referral, and communication of diagnosis and follow-up advice, assessed at day 0 exit interview.

RESULTS

We recruited 1929 children, of which 1021 (53%) attended ALMANACH facilities, between March and September 2020. Caregiver-reported recovery was significantly higher among children attending ALMANACH facilities (adjusted OR=2·63, 95% CI 1·60 to 4·32). We observed higher parenteral and lower oral antimicrobial prescription rates (adjusted OR=2·42 (1·00 to 5·85) and adjusted OR=0·40 (0·22 to 0·73), respectively) in ALMANACH facilities as well as markedly higher rates for referral, communication of diagnosis, and follow-up advice.

CONCLUSION

Implementation of digital CDSS with training, mentorship and feedback in primary care can improve quality of care and recovery of sick children in resource-constrained settings, likely mediated by better guideline adherence. These findings support the use of CDSS for health systems strengthening to progress towards universal health coverage.

Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia

Background

In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce.

Methods

We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals.

Results

A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies.

Conclusions

The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13549-3.

Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys

BACKGROUND

Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators.

METHODS

A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level.

RESULTS

Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity.

CONCLUSION

Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.

Hypoxemia, hypoglycemia and IMCI danger signs in pediatric outpatients in Malawi

Hypoxemia and hypoglycemia are known risks for mortality in children in low-income settings. Routine screening with pulse oximetry and blood glucose assessments for outpatients could assist in early identification of high-risk children. We assessed the prevalence of hypoglycemia and hypoxemia, and the overlap with Integrated Management of Childhood Illness (IMCI) general danger signs, among children seeking outpatient care in Malawi. A cross-sectional study was conducted at 14 government primary care facilities, four rural hospitals and one district referral hospital in Mchinji district, Malawi from August 2019-April 2020. All children aged 0-12 years seeking care with an acute illness were assessed on one day per month in each facility. Study research assistants measured oxygen saturation using Lifebox LB-01 pulse oximeter and blood glucose was assessed with AccuCheck Aviva glucometers. World Health Organization definitions were used for severe hypoglycemia (<2.5mmol/l) and hypoxemia (SpO2 <90%). Moderate hypoglycemia (2.5-4.0mmol/l) and hypoxemia (SpO2 90-93%) were also calculated and prevalence levels compared between those with and without IMCI danger signs using chi2 tests. In total 2,943 children were enrolled, with a median age of 41 (range: 0-144) months. The prevalence of severe hypoxemia was 0.6% and moderate hypoxemia 5.4%. Severe hypoglycemia was present in 0.1% of children and moderate hypoglycemia in 11.1%. IMCI general danger signs were present in 29.3% of children. All severely hypoglycemic children presented with an IMCI danger sign (p <0.001), but only 23.5% of the severely hypoxemic and 31.7% of the moderately hypoxemic children. We conclude that while the prevalence of severe hypoxemia and hypoglycemia were low, moderate levels were not uncommon and could potentially be useful as an objective tool to determine referral needs. IMCI danger signs identified hypoglycemic children, but results highlight the challenge to detect hypoxemia. Future studies should explore case management strategies for moderate hypoxemia and hypoglycemia.

Acute respiratory infections (ARIs) and factors associated with their poor clinical outcome among children under-five years attending pediatric wards of public hospital in Southwest district of Ethiopia: A prospective observational cohort study

This study was designed to assess the prevalence and factors associated with poor clinical outcome of acute respiratory infections (ARIs) among children less than five years of age at Mizan-Tepi university teaching public hospital in southwest district of Ethiopia. A prospective observational cohort study design was conducted from 01 June to August 30, 2020. Data related to socio-demographics, child nutritional status, clinical and environmental characteristics of patients were collected with structured questionnaire. Follow-up data were gathered from patient’s medical records using standard data collection tool. The data were analyzed using SPSS versions 25.0. In this study, 305 children of age less than five years were included. Of these, 124 (40.7%) of children were diagnosed with ARIs, of which 66 (53.2%) were female and 69 (55.6%) were age of 24–59 months. Of children diagnosed with ARIs, 21 (16.9%) were ended with poor clinical outcomes after completion of their treatment. In the multivariate analysis, age of children and presence of any other disease conditions (OR = 0.331; 95% CI: 0.123– 0.880; p= 0.024), exposure to indoor air pollution (OR = 0.344; 95% CI: 0.128– 0.925; p= 0.030),  malnutrition (OR = 0.175; 95% CI: 0.058– 0.523; p= 0.002) and end point pneumonia (OR = 0.305; 95% CI: 0.113–0.821; p= 0.015) were found to be independent factors for poor outcome of under-five children with ARIs. Our findings highlight that timely detection, proper management and treatments as well as addressing other contributing factors are essentials in order to reduce prevalence and poor clinical outcomes of under five children with ARIs.

High Frequency of Antibiotic Prescription in Children With Undifferentiated Febrile Illness in Kenya

BACKGROUND

In low-resource, malaria-endemic settings, accurate diagnosis of febrile illness in children is challenging. The World Health Organization (WHO) currently recommends laboratory-confirmed diagnosis of malaria prior to starting treatment in stable children. Factors guiding management of children with undifferentiated febrile illness outside of malaria are not well understood.

METHODS

This study examined clinical presentation and management of a cohort of febrile Kenyan children at 5 hospital/clinic sites from January 2014 to December 2017. Chi-squared and multivariate regression analyses were used to compare frequencies and correlate demographic, environmental, and clinical factors with patient diagnosis and prescription of antibiotics.

RESULTS

Of 5735 total participants, 68% were prescribed antibiotic treatment (n = 3902), despite only 28% given a diagnosis of bacterial illness (n = 1589). Factors associated with prescription of antibiotic therapy included: negative malaria testing, reporting head, ears, eyes, nose and throat (HEENT) symptoms (ie, cough, runny nose), HEENT findings on exam (ie, nasal discharge, red throat), and having a flush toilet in the home (likely a surrogate for higher socioeconomic status).

CONCLUSION

In a cohort of acutely ill Kenyan children, prescription of antimalarial therapy and malaria test results were well correlated, whereas antibiotic treatment was prescribed empirically to most of those who tested malaria negative. Clinical management of febrile children in these settings is difficult, given the lack of diagnostic testing. Providers may benefit from improved clinical education and implementation of enhanced guidelines in this era of malaria testing, as their management strategies must rely primarily on critical thinking and decision-making skills.

Family and provider perceptions of quality of care in the management of sick young infants in primary healthcare settings in four counties of Kenya

Background

Understanding the perceptions of quality of care given to sick young infants in primary healthcare settings is key for developing strategies for effective uptake and utilisation of possible severe bacterial infection guidelines. The purpose of this study is to assess families and providers’ perceptions of care given to sick young infants at primary healthcare facilities in four diverse counties in Kenya.

Methods

A cross-sectional qualitative design involving 37 in-depth interviews and 39 focus group discussions with very young (15–18 years), young (19–24 years) and older (25–45 years) caregivers of young infants aged 0–59 days; and key informant interviews with community-based and facility-based front-line health providers (14) in primary healthcare facilities. Qualitative data were captured using audio tapes and field notes, transcribed, translated and exported into QSR NVivo V.12 for analysis. A thematic framework approach was adopted to classify and analyse data.

Results

Perceived care given to sick young infants was described around six domains of the WHO framework for the quality of maternal and newborn healthcare: evidence-based practices for routine and emergency care; functional referral systems; effective communication; respect and preservation of dignity; availability of competent, motivated human resources; and availability of physical resources. Views of caregivers and providers regarding sick young infant care in primary healthcare settings were similar across the four sites. Main hindrance to sick young infant care includes stockout of essential drugs, limited infrastructure, lack of functional referral system, inadequate providers which led to delays in receiving treatment, inadequate provider skills and poor provider attitudes. Despite these challenges, motivation and teamwork of health providers were key tenets in care provision.

Conclusion

The findings underscore the need to prioritise improving quality of sick young infant services at primary healthcare settings by building capacity of providers through training, ensuring continuous supply of essential medicines and equipment and improving infrastructure including referral.

Tanzanian primary healthcare workers' experiences of antibiotic prescription and understanding of antibiotic resistance in common childhood infections: a qualitative phenomenographic study

Background

Antibiotic resistance is a threat to global child health. Primary healthcare workers play a key role in antibiotic stewardship in the community, but few studies in low-income countries have described their experiences of initiating antibiotic treatment in children. Thus, the present study aimed to describe primary healthcare workers’ experiences of antibiotic prescription for children under 5 years of age and their conceptions of antibiotic resistance in Northern Tanzania.

Methods

A qualitative study involving individual in-depth interviews with 20 prescribing primary healthcare workers in Moshi urban and rural districts, Northern Tanzania, was performed in 2019. Interviews were transcribed verbatim, translated from Kiswahili into English and analysed according to the phenomenographic approach.

Findings

Four conceptual themes emerged during the analysis; conceptions in relation to the prescriber, the mother and child, other healthcare actors and in relation to outcome. The healthcare workers relied mainly on clinical examination and medical history provided by the mother to determine the need for antibiotics. Confidence in giving advice concerning non-antibiotic treatment varied among the participants and expectations of antibiotic treatment were perceived to be common among the mothers. Antibiotic resistance was mainly perceived as a problem for the individual patient who was misusing the antibiotics.

Conclusions

To increase rational antibiotic prescription, an awareness needs to be raised among Tanzanian primary healthcare workers of the threat of antibiotic resistance, not only to a few individuals, but to public health. Guidelines on childhood illnesses should be updated with advice concerning symptomatic treatment when antibiotics are not necessary, to support rational prescribing practices and promote trust in the clinician and mother relationship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00952-5.

An Integrated eDiagnosis Approach (IeDA) versus standard IMCI for assessing and managing childhood illness in Burkina Faso: a stepped-wedge cluster randomised trial

BACKGROUND

The Integrated eDiagnosis Approach (IeDA), centred on an electronic Clinical Decision Support System (eCDSS) developed in line with national Integrated Management of Childhood Illness (IMCI) guidelines, was implemented in primary health facilities of two regions of Burkina Faso. An evaluation was performed using a stepped-wedge cluster randomised design with the aim of determining whether the IeDA intervention increased Health Care Workers' (HCW) adherence to the IMCI guidelines.

METHODS

Ten randomly selected facilities per district were visited at each step by two trained nurses: One observed under-five consultations and the second conducted a repeat consultation. The primary outcomes were: overall adherence to clinical assessment tasks; overall correct classification ignoring the severity of the classifications; and overall correct prescription according to HCWs' classifications. Statistical comparisons between trial arms were performed on cluster/step-level summaries.

RESULTS

On average, 54 and 79% of clinical assessment tasks were observed to be completed by HCWs in the control and intervention districts respectively (cluster-level mean difference = 29.9%; P-value = 0.002). The proportion of children for whom the validation nurses and the HCWs recorded the same classifications (ignoring the severity) was 73 and 79% in the control and intervention districts respectively (cluster-level mean difference = 10.1%; P-value = 0.004). The proportion of children who received correct prescriptions in accordance with HCWs' classifications were similar across arms, 78% in the control arm and 77% in the intervention arm (cluster-level mean difference = - 1.1%; P-value = 0.788).

CONCLUSION

The IeDA intervention improved substantially HCWs' adherence to IMCI's clinical assessment tasks, leading to some overall increase in correct classifications but to no overall improvement in correct prescriptions. The largest improvements tended to be observed for less common conditions. For more common conditions, HCWs in the control districts performed relatively well, thus limiting the scope to detect an overall impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02341469 ; First submitted August 272,014, posted January 19, 2015.

Primary Care Case Management of Febrile Children: Insights From the ePOCT Routine Care Cohort in Dar es Salaam, Tanzania

Aim: To provide insight in the primary health care (PHC) case management of febrile children under-five in Dar es Salaam, and to identify areas for improving quality of care. Methods: We used data from the routine care arm of the ePOCT trial, including children aged 2-59 months who presented with an acute febrile illness to two health centers in Dar es Salaam (2014-2016). The presenting complaint, anthropometrics, vital signs, test results, final diagnosis, and treatment were prospectively collected in all children. We used descriptive statistics to analyze the frequencies of diagnoses, adherence to diagnostics, and prescribed treatments. Results: We included 547 children (47% male, median age 14 months). Most diagnoses were viral: upper respiratory tract infection (60%) and/or gastro-enteritis (18%). Vital signs and anthropometric measurements taken by research staff and urinary testing failed to influence treatment decisions. In total, 518/547 (95%) children received antibiotics, while 119/547 (22%) had an indication for antibiotics based on local guidelines. Antibiotic dosing was frequently out of range. Non-recommended treatments were common (29%), most often cough syrup and vitamins. Conclusion: Our study points to challenges in using diagnostic test results, concerns regarding quality of antibiotic prescriptions, and frequent use of non-evidence-based complementary medicines in PHC in Tanzania. Larger studies on diagnostic and treatments processes in PHC in Tanzania are needed to inform effective solutions to support PHC workers in case management of children.

Improving the Assessment and Classification of Sick Children according to the Integrated Management of Childhood Illness (IMCI) Protocol at Sanja Primary Hospital, Northwest Ethiopia: A Pre-Post Interventional Study

Background

A complete and consistent use of integrated management of childhood illness (IMCI) protocol is a strategic implementation that has been used to promote the accurate assessment and classifications of childhood illnesses, ensures appropriate combined treatment, strengthens the counseling of caregiver, and speeds up the referrals to decrease child mortality and morbidity. However, there is limited evidence about the complete and consistent use of IMCI protocol during the assessment and classifications of childhood illness in Ethiopia. Therefore, this intervention was implemented to improve the assessment and classifications of childhood illness according to the IMCI protocol in Sanja primary hospital, northwest Ethiopia.

Methods

A pre-post interventional study was used in Sanja primary hospital from January 01 to May 30, 2019. A total of 762 (381 for pre and 381 for postintervention) children from 2 months up to 5 years of age were involved in the study. Data were collected using a structured questionnaire prepared from the IMCI guideline, and a facility checklist was used. A five-month in-service training, weekly supportive supervision, daily morning session, and availing essential drugs and materials were done. Both the descriptive statistics and independent t-test were done. In the independent t-test, a p value of <0.05 and a mean difference with 95% CI were used to declare the significance of the interventions.

Results

The findings revealed that the overall completeness of the assessment was improved from 37.8 to 79.8% (mean difference: 0.17; 95% CI: 0.10-0.22), consistency of assessment with classification from 47.5 to 76.9% (mean difference: 0.34; 95% CI: 0.27-0.39), classification with treatment from 42.3 to 75.4% (mean difference: 0.35; 95% CI: 0.28-0.47), and classification with follow-up from 32.8 to 73.0% (mean difference: 0.36; 95% CI: 0.29-0.42).

Conclusion

The intervention has a significant improvement in the assessment and classification of childhood illness according to the IMCI protocol. Therefore, steps must be taken to ensure high quality of training, adequate supervision including the observation of health workers managing sick children during supervisory visits, and a constant supply of essential drugs and job aids for successful implementation of IMCI in the hospital and also to other facilities.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

Objective

To determine the effect of social accountability strategies on pediatric quality of care.

Design and Setting

A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included.

Participants

Five patients under 5 years and their caretakers were randomly selected in each facility.

Interventions

To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care.

Outcome Measures

Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers.

Results

Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P &lt; 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P &lt; 0.041), lethargy (86.7% vs 40%, P &lt; 0.004) and convulsions (83.3 vs 46.7%, P &lt; 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P &lt; 0.000), immunization card (90% vs 40%, P &lt; 0.002), child weight (100 vs 86.7, P &lt; 0.041) and checking growth chart (96.7% vs 66.7%, P &lt; 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P &lt; 0.018, counseling index 2.7 vs 1.5, P &lt; 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities.

Conclusion

The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

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.

Challenges facing professional nurses implementing the Integrated Management of Childhood Illness programme in rural primary health care clinics, Limpopo Province, South Africa

BACKGROUND

Under-five mortality and morbidity could be reduced through increased implementation of the Integrated Management of Childhood Illness (IMCI) strategy. The aim of the study was to determine challenges facing IMCI-trained professional nurses on implementing this strategy when managing children less than 5 years of age.

METHODS

A quantitative descriptive survey method was used. The target populations were IMCI-trained professional nurses with the sample of 208 respondents. Data were collected through self-report questionnaires and analysed using statistical analysis system software.

RESULTS

The implementation of the IMCI strategy by IMCI-trained professional nurses in Vhembe primary health care (PHC) clinics continues to face challenges, making it difficult for professional nurses to follow guidelines. These challenges range from staff barriers, management barriers, poor management process and poor infrastructure. All these challenges lead to poor-quality under-five patient care.

CONCLUSION

Regardless of the IMCI strategy being implemented since its inception in 1999, the under-five mortality remains not reduced. This is related to the identified challenges facing the IMCI-trained professional nurses implementing the strategy.

Key challenges of health care workers in implementing the integrated management of childhood illnesses (IMCI) program: a scoping review

Background: Several evaluative studies demonstrate that a well-coordinated Integrated Management of Childhood Illnesses (IMCI) program can reduce child mortality. However, there is dearth of information on how frontline providers perceive IMCI and how, in their view, the program is implemented and how it could be refined and revitalized.Purpose: To determine the key challenges affecting IMCI implementation from the perspective of health care workers (HCWs) in primary health care facilities.Methods: A scoping review based on the five-step framework of Arskey and O'Malley was utilized to identify key challenges faced by HCWs implementing the IMCI program in primary health care facilities. A comprehensive search of peer-reviewed literature through PubMed, ScienceDirect, EBSCOhost and Google Scholar was conducted. A total of 1,475 publications were screened for eligibility and 41 publications identified for full-text evaluation. Twenty-four (24) published articles met our inclusion criteria, and were investigated to tease out common themes related to challenges of HCWs in terms of implementing the IMCI program.Results: Four key challenges emerged from our analysis: 1) Insufficient financial resources to fund program activities, 2) Lack of training, mentoring and supervision from the tertiary level, 3) Length of time required for effective and meaningful IMCI consultations conflicts with competing demands and 4) Lack of planning and coordination between policy makers and implementers resulting in ambiguity of roles and accountability. Although the IMCI program can provide substantial benefits, more information is still needed regarding implementation processes and acceptability in primary health care settings.Conclusion: Recognizing and understanding insights of those enacting health programs such as IMCI can spark meaningful strategic recommendations to improve IMCI program effectiveness. This review suggests four domains that merit consideration in the context of efforts to scale and expand IMCI programs.

Quality of care for children with severe disease in the Democratic Republic of the Congo

BACKGROUND

Despite the almost universal adoption of Integrated Management of Childhood Illness (IMCI) guidelines for the diagnosis and treatment of sick children under the age of five in low- and middle-income countries, child mortality remains high in many settings. One possible explanation of the continued high mortality burden is lack of compliance with diagnostic and treatment protocols. We test this hypothesis in a sample of children with severe illness in the Democratic Republic of the Congo (DRC).

METHODS

One thousand one hundred eighty under-five clinical visits were observed across a regionally representative sample of 321 facilities in the DRC. Based on a detailed list of disease symptoms observed, patients with severe febrile disease (including malaria), severe pneumonia, and severe dehydration were identified. For all three disease categories, treatments were then compared to recommended case management following IMCI guidelines.

RESULTS

Out of 1180 under-five consultations observed, 332 patients (28%) had signs of severe febrile disease, 189 patients (16%) had signs of severe pneumonia, and 19 patients (2%) had signs of severe dehydration. Overall, providers gave the IMCI-recommended treatment in 42% of cases of these three severe diseases. Less than 15% of children with severe disease were recommended to receive in-patient care either in the facility they visited or in a higher-level facility.

CONCLUSIONS

These results suggest that adherence to IMCI protocols for severe disease remains remarkably low in the DRC. There is a critical need to identify and implement effective approaches for improving the quality of care for severely ill children in settings with high child mortality.

Introducing post-discharge malaria chemoprevention (PMC) for management of severe anemia in Malawian children: a qualitative study of community health workers' perceptions and motivation

Background

Severe malarial anaemia is one of the leading causes of paediatric hospital admissions in Malawi. Post-discharge malaria chemoprevention (PMC) is the intermittent administration of full treatment courses of antimalarial to children recovering from severe anaemia and findings suggest that this intervention significantly reduces readmissions and deaths in these children. Community delivery of health interventions utilizing community health workers (CHWs) has been successful in some programmes and not very positive in others. In Malawi, there is an on-going cluster randomised trial that aims to find the optimum strategy for delivery of dihydroartemesinin-piperaquine (DHP) for PMC in children with severe anaemia. Our qualitative study aimed to explore the feasibility of utilizing CHWs also known as health surveillance assistants (HSAs) to remind caregivers to administer PMC medication in the existing Malawian health system.

Methods

Between December 2016 and March 2018, 20 individual in-depth-interviews (IDIs) and 2 focus group discussions (FGDs) were conducted with 39 HSAs who had the responsibility of conducting home visits to remind caregivers of children who were prescribed PMC medication in the trial. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were uploaded to NVIVO 11 and analysed using the thematic framework analysis method.

Results

Although intrinsic motivation was reportedly high, adherence to the required number of home visits was very poor with only 10 HSAs reporting full adherence. Positive factors for adherence were the knowledge and perception of the effectiveness of PMC and the recognition from the community as well as health system. Poor training, lack of supervision, high workload, as well as technical and structural difficulties; were reported barriers to adherence by the HSAs.

Conclusions

Post-discharge malaria chemoprevention with DHP is perceived as a positive approach to manage children recovering from severe anaemia by HSAs in Malawi. However, adherence to home visit reminders was very poor and the involvement of HSAs in a scale up of this intervention may pose a challenge in the existing Malawian health system.

Trial registration

ClinicalTrials.gov identifier NCT02721420. The trial was registered on 26 March 2016.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3791-5) contains supplementary material, which is available to authorized users.

Consistency of Integrated Management of Newborn and Childhood Illness (IMNCI) in Shire Governmental Health Institution in 2017

Objective

In an effort to reduce infant mortality and morbidity, the World Health Organization and other technical partners developed the Integrated Management of Newborn and Childhood Illness (IMNCI). This study focuses on assessment of consistency and completeness of integrated management of neonatal and child hood illness in primary health care units.

Results

A total of 384 cases were taken from 3562 cases both from young infant registration (under-2 month old) and child registration (2 months–5 year old). Out of 384 cases, 241 (62.8%) cases were correctly classified and 143 (37.2%) were incorrect classifications. Similarly 164 (42.7%) cases were treated correctly where as 220 (57.3%) treated incorrectly. Only 95 (24.7%) cases have given appropriate appointments where as 289 (75.3%) cases were appointed incorrectly. The overall consistency of IMNCI management is poor. Unless continuous follow up of and training was given, children are not treated as expected. More over using electronic method of IMNCI may alleviate the problem.