Challenges to the implementation of the integrated management of childhood illness (IMCI) at community health centres in West Java province, Indonesia

The Impact of integrated management of childhood illness training on knowledge levels of healthcare workers in Botswana

The Integrated Management of Childhood Illness (IMCI) strategy was developed to improve outcomes through integration of preventive and curative interventions in countries with high mortality. This study aimed to assess the impact of IMCI training on the knowledge levels of healthcare workers (HCWs) in Botswana, comparing the trained with the non-trained. This was a cross-sectional study from a national IMCI survey across all 27-health districts of Botswana in September 2023. Within each district, random sampling was used to select 10 healthcare facilities (HCFs) to be included in the survey. HCFs were ordered by their size to ensure that all types were represented. The demographics, training and qualifications of the HCWs were documented. Stata 13.1 software was used for analysis, and data was summarized with frequencies and percentages. Pearson's chi square test was used to compare the performances of IMCI trained versus non-IMCI trained HCWs. A p-value of <0.05 was considered statistically significant. A total of 964 HCWs participated in the survey. The most frequent cadre was General Nurse with 385 (40.7%) participants. Participants trained in IMCI were 471 (49.2%) and those who consult sick children were 615 (65.1%). Those who were IMCI trained had good (80-100%) and moderate (60-79%) knowledge levels at 51 (14.1%) and 91 (25.2%) participants respectively than those who had no IMCI training at 25 (9.9%) for good and 52 (20.6%) for moderate performances. HCWs who were not IMCI trained had poor performance (0-59%) at 175 (69.4%) participants while the IMCI trained had poor performance at 219 (60.7%). The performances showed no statistically significant difference (p = 0.092), reflective of similar knowledge levels. Overall, the performance of IMCI trained HCWs was not significantly different from those not IMCI trained, translating to that IMCI training does not have effect on knowledge levels of HCWs in management of childhood illness. This, however, should be interpreted with caution since it could be due to the stated study limitations. A future IMCI study on knowledge, attitudes and practices (KAP) or a longitudinal study would be more beneficial.

Evaluation the Effectiveness of Abridged IMNCI (7-Day) Course v Standard (11-Day) Course in Pakistan

BACKGROUND

The conventional IMCI training for healthcare providers is delivered in 11 days, which can be expensive and disruptive to the normal clinical routines of the providers. An equally effective, shorter training course may address these challenges.

METHODS

We conducted a quasi-experimental study in two provinces (Sindh and Punjab) of Pakistan. 104 healthcare providers were conveniently selected to receive either the abridged (7-day) or the standard (11-day) training. Knowledge and clinical skills of the participants were assessed before, immediately on conclusion of, and six months after the training.

RESULTS

The improvement in mean knowledge scores of the 7-day and 11-day training groups was 31.6 (95% CI 24.3, 38.8) and 29.4 (95% CI 23.9, 34.9) respectively, p = 0.630 while the improvement in mean clinical skills scores of the 7-day and 11-day training groups was 23.8 (95% CI: 19.3, 28.2) and 23.0 (95% CI 18.9, 27.0) respectively, p = 0.784. The decline in mean knowledge scores six months after the training was - 12.4 (95% CI - 18.5, - 6.4) and - 6.4 (95% CI - 10.5, - 2.3) in the 7-day and 11-day groups respectively, p = 0.094. The decline in mean clinical skills scores six months after the training was - 6.3 (95% CI - 11.3, - 1.3) in the 7-day training group and - 9.1 (95% CI - 11.5, - 6.6) in the 11-day group, p = 0.308.

CONCLUSION

An abridged IMNCI training is equally effective as the standard training. However, training for certain illnesses may be better delivered by the standard course.

Evaluation of the Implementation of Integrated Management of Childhood Illness in Special Region of Yogyakarta Province, Indonesia

BACKGROUND: Child mortality rate in Indonesia is now fluctuating. The Province of the Special Region of Yogyakarta (DIY) had fluctuated infant mortality rate in the recent years. As a result, guidelines of Integrated Management of Childhood Illness (IMCI) are still required to improve the health of Indonesian children. AIM: This study aimed to explore the implementation of IMCI in DIY Province in terms of input, process, and output components. METHODS: A case study approach with a qualitative method was conducted among implementers of IMCI in the DIY Province. The data were obtained from secondary sources, such as the reports, attendance lists, and focus group discussion video recordings. RESULTS: The results were differentiated by input, process, and output components. Most IMCI implementers have not received special training (input); there were no specific guidelines for sick children during the COVID-19 pandemic (process); and the IMCI implementation target has not been achieved with the percentage below 60–70% (output). CONCLUSION: The implementation of IMCI in Yogyakarta Province is still required to improve the quality of services provided to sick children.

"The staff are not motivated anymore": Health care worker perspectives on the Integrated Management of Childhood Illness (IMCI) program in the Philippines

BACKGROUND

Studies focusing on the Integrated Management of Childhood Illness (IMCI) program in the Philippines are limited, and perspectives of frontline health care workers (HCWs) are largely absent in relation to the introduction and current implementation of the program. Here, we describe the operational challenges and opportunities described by HCWs implementing IMCI in five regions of the Philippines. These perspectives can provide insights into how IMCI can be strengthened as the program matures, in the Philippines and beyond.

METHODS

In-depth interviews (IDIs) were conducted with HCWs (n = 46) in five provinces (Ilocos Sur, Quezon, National Capital Region, Bohol and Davao), with full transcription and translation as necessary. In parallel, data collectors observed the status (availability and placement) of IMCI-related materials in facilities. All data were coded using NVivo 12 software and arranged along a Social Ecological Model.

RESULTS

HCWs spoke of the benefits of IMCI and discussed how they developed workarounds to ensure that integral components of the program could be delivered in frontline facilities. Five key challenges emerged in relation to IMCI implementation in primary health care (PHC) facilities: 1) insufficient financial resources to fund program activities, 2) inadequate training, mentoring and supervision among and for providers, 3) fragmented leadership and governance, 4) substandard access to IMCI relevant written documents, and 5) professional hierarchies that challenge fidelity to IMCI protocols.

CONCLUSION

Although the IMCI program was viewed by HCWs as holistic and as providing substantial benefits to the community, more viable implementation processes are needed to bolster acceptability in PHC facilities.

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.

Assessment of Factors Affecting the Implementation of Integrated Management of Neonatal and Childhood Illness for Treatment of under Five Children by Health Professional in Health Care Facilities in Yifat Cluster in North Shewa Zone, Amhara Region, Ethiopia

BACKGROUND

Every year some 12 million children in developing countries die before they reach their fifth birthday. Seven in ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhea, measles, malaria or malnutrition. The WHO Department of Child and Adolescent Health and Development (CAH), in collaboration with eleven other WHO programmes and UNICEF, has responded to this challenge by developing the Integrated Management of Childhood Illness (IMCI) strategy. Research that examines assessment of factors influencing the implementing the integrated management of neonatal and childhood illnesses (IMCI) strategy in Ethiopia is limited.

OBJECTIVE

To assess factors influencing the implementation of the IMNCI strategy by health professionals in public health institutions of Yifat cluster in North Shewa zone, Ethiopia, 2018.

METHOD

An institutional based cross-sectional study will be conducted from March to May. A total of 201 health professionals will be selected using proportionally allocated to population size and interviewed using structured and pretested questionnaires. Data will be coded, entered and cleaned using SPSS version 20 for analysis. Univariate (frequency), Bivariate, Multiple logistic regression analysis will be employed. P-value and 95% confidence interval (CI) for OR will be used in judging the significance of the associations. P-value less than 0.05 will be taken as significant association.

RESULTS

Data were obtained from 201 health care professionals, yielding a response rate of 100%. The overall IMNCI implementation was 58% as high level implementation and 42% as low level implementation. In multivariate analysis the implementation of IMNCI was higher among IMNCI trained health care professionals ([AOR = 2.7, 95% CI: (1.1.278, 4.562)]) and among those whose always referring chart booklet [AOR = 2.76, 95% CI: (1.753, 5.975)].

CONCLUSION

IMNCI strategy can be better implemented through provision of training for the health workers. However, a variety of factor found to be a barrier to IMNCI implementation in a consistent way. Recommendations have been made related to provision of the training to the nurses and Health Care system strengthening among others.

Use of antibiotics for common illnesses among children aged under 5 years in a rural community in Indonesia: a cross-sectional study

Background

The incidence of antimicrobial resistance has been increasing worldwide in the past decades, which includes resistance to bacteria that cause common childhood illnesses, such as acute respiratory infections and diarrhea. Numerous children with those common illnesses are treated with antibiotics. However, in such cases, antibiotic treatment is not required. Community-based studies focusing on antibiotic use among children are still limited. This study aimed to identify the prevalence of antibiotic use for common childhood illnesses and to investigate factors associated with antibiotic use in children under 5 years old as well as female caregivers in a rural community in Indonesia.

Methods

A cross-sectional study of 334 children in three villages of Banten Province, located in the western part of Java Island, was conducted in May 2018. Female caregivers who were responsible for providing medications to children were interviewed. We obtained information such as demographic data, any common clinical illness within the last 30 days, and antibiotic usage during an episode of illness. We excluded children with underlying disease that require a regular follow-up and children who were hospitalized in the last 30 days in the analysis. Antibiotic use answered by female caregivers was verified by checking its package or showing photos of various antibiotics to the female caregivers. Crushed antibiotics were confirmed with health professionals.

Results

A total of 203 children had clinical symptoms, and the most common symptom was fever and respiratory symptoms. In total, 49.3% received antibiotics, and 66% of them were prescribed by private health professionals. Only two children received antibiotics without a prescription. The most common antibiotic used among children was amoxicillin.

Conclusions

The high prevalence of antibiotic use was observed in children under 5 years of age, and the major source to obtain antibiotics was to consult health professionals. Training on appropriate antibiotic use must be conducted for health professionals in not only public but also private sectors.

Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on

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.

Evaluation of distance learning IMCI training program: the case of Tanzania

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.

Improving Access to Child Health Care in Indonesia Through Community Case Management

Objectives In order to reduce infant mortality in Indonesia, community case management (CCM) was introduced. CCM is a community-based service delivery model to improve children's wellness and longevity, involving the delivery of lifesaving, curative interventions to address common childhood illnesses, particularly where there are limited facility-based services. This paper reports the findings of a qualitative study that investigated the implementation of CCM in the Kutai Timur district, East Kalimantan Indonesia from the perspective of mothers who received care. Methods Seven mothers and health workers were observed during a consultation and these mothers were interviewed in their home weeks after delivery. Field notes and the interview transcriptions were analysed thematically. Findings Mothers reported that their access to care had improved, along with an increase in their knowledge of infant danger signs and when to seek care. Family compliance with care plans was also found to have improved. Mothers expressed satisfaction with the care provided under the CCM model. The mothers expressed a need for a nurse or midwife to be posted in each village, preferably someone from that village. However two mothers did not wish their children to receive health interventions as they did not believe these to be culturally appropriate. Conclusion CCM is seen by rural Indonesian mothers to be a helpful model of care in terms of increasing access to health care and the uptake of lifesaving interventions for sick children. However there is a need to modify the program to demonstrate cultural sensitivity and meet cultural needs of the target population. While CCM is a potentially effective model of care, further integrative strategies are required to embed this model into maternal and child health service delivery.

The Assessment, Evaluation, and Management of the Critically Ill Child When Resources are Limited-Southeast Asian Perspective

The Southeast Asia region comprises 10 independent countries with highly divergent health systems and health status. The heterogeneity in infant and child mortality rates suggests that there is still scope for improvement in the care of critically ill children. There is, however, a paucity of published data on outcomes and processes of care that could affect planning and implementation of intervention programs. Significant challenges in the delivery of care for the critically ill child remain, especially in pre-hospital and in-hospital triaging and emergency care and inpatient hospital care. Potential areas for continued improvement include strengthening of health systems through sustained commitment by local governments, capacity building, and sharing of research output. Simple, low cost, locally available, and effective solutions should be sought. The introduction of standards and auditing tools can assist in determining effectiveness and outcomes of intervention packages that are adapted to local settings. Recognition and acknowledgment of shortfalls between expectations and outcomes is a first step to overcoming some of these obstacles necessary to achieve a seamless interface among pre-hospital, emergency, inpatient, and critical care delivery processes that would improve survival of critically ill children in this region.