Effect of adopting integrated management of childhood illness guidelines on drug use at a primary health care center: a case study from Egypt

Quality of Integrated Management of Newborn and Childhood Illness Services at Health Centers in Jimma, Southwest Ethiopia

BACKGROUND

The Integrated Management of Newborn and Childhood Illness (IMNCI) strategy includes both preventive and curative interventions to improve practices in health facilities, the health system and at home. The quality of these interventions has been very rarely subjected to scientific inquiry in Ethiopia. This study assessed quality of IMNCI services in health centers of Jimma, South West Ethiopia, 2014.

METHODS

A facility based cross-sectional study was conducted from March 2-15, 2014 in the health centers of Jimma among 411 care takers exit interview and total of 60 consultation sessions were observed using checklist and participants enrolled through convenient sampling technique. Descriptive statistics were used and factor analysis was employed to create measurement scales for satisfaction of caretakers. Factor scores were used in linear regression analyses to determine presence of statistically significant association between explanatory variables and the outcome variable at P value <0.05.

RESULTS

The response rate for the exit interview was 411 (97.4%). The mean score of overall caretakers satisfaction was 63.4. Specifically 23.4%, 33.6%, and 19.2% of the respondents were dissatisfied with waiting time, amount of explanation they received about the problem or treatment, and availability of medicines, respectively. Availability of prescribed medications (95% CI: 0.577 to 0.047), receiving first dose of medication at health facility (95% CI: 0.087, 0.552), receiving laboratory services (95% CI:0.455,0.056) were among factors that significantly associated with the caretakers' satisfaction score.

CONCLUSION AND RECOMMENDATIONS

Perceived mean of caretakers' satisfaction at the health centers of Jimma town was low as compared to national standards and long waiting time while providing services. Availability of prescribed medications, receiving first dose of medication and receiving laboratory services were factors associated with patients' satisfaction. Respective health centers need to ensure availability of medications and supplies and professionals need to pay special attention on medical services like laboratory services, medication and decrease waiting time while providing health services.

Antibiotic prescription for febrile outpatients: a health facility-based secondary data analysis for the Greater Accra region of Ghana

Background

Misguided prescription of antibiotics is an important contributor towards the emergence and spread of antibiotic resistance. The absence of effective interventions to control antibiotic use leads to increased consumption beyond the needed requirements. Antibiotic stewardship interventions must be appropriately targeted and assessed to enhance the controlled use of antibiotics. The objective of this study was to determine the factors associated with antibiotic prescription to febrile outpatients who seek care in health facilities within the Greater Accra region of Ghana.

Methods

Secondary data obtained from the medical records of 2519 febrile outpatients, consecutively sampled at the outpatient department of 6 health facilities in 3 municipalities during the baseline survey of a quasi-experiment in 2015 was used. The primary outcome was prescription of any antibiotic. Independent variables included patients’ demographics, symptoms, laboratory investigations (blood film microscopy, malaria rapid diagnostic test, full blood count, urine and stool routine examinations), diagnoses, and prescribers’ demographics. Crude and adjusted logistic regression analyses were used to determine the factors associated with antibiotic prescription.

Results

The prevalence of antibiotic prescription was 70.1% (95% CI: 67.7–72.4). Prescribers with more years of practice (> 5 years) were more likely to prescribe antibiotics compared to those with less than 3 years of practice (p <  0.001). Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training was associated with a 2.3 (95% CI: 1.54, 3.53, p <  0.001) fold odds of antibiotic prescribing. Patients aged 5 years or more were 60% less likely to receive antibiotics compared with those under 5 years (AOR = 0.40, 95% CI: 0.32, 0.51; p <  0.001). Patients referred for laboratory investigations were 29% less likely to be prescribed antibiotics than those not referred. The presence of cough as a presenting symptom was associated with a 3.5 (95% CI: 2.54, 4.92) fold odds of antibiotic prescription.

Conclusion

Prescription of antibiotics to febrile outpatients was high. Promoting laboratory testing can potentially reduce irrational antibiotic prescription. Prescribing antibiotics for children under five and the prescribing practices of prescribers with longer years of practice should be targeted with interventions to reduce high use of antibiotics.

Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.

METHODS AND FINDINGS

We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies' estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.

CONCLUSIONS

Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019123269.

Integrated management of childhood illness (IMCI) strategy for children under five

BACKGROUND

More than 7.5 million children younger than age five living in low- and middle-income countries die every year. The World Health Organization (WHO) developed the integrated management of childhood illness (IMCI) strategy to reduce mortality and morbidity and to improve quality of care by improving the delivery of a variety of curative and preventive medical and behavioral interventions at health facilities, at home, and in the community.

OBJECTIVES

To evaluate the effects of programs that implement the IMCI strategy in terms of death, nutritional status, quality of care, coverage with IMCI deliverables, and satisfaction of beneficiaries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE; EMBASE, Ovid; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EbscoHost; the Latin American Caribbean Health Sciences Literature (LILACS), Virtual Health Library (VHL); the WHO Library & Information Networks for Knowledge Database (WHOLIS); the Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Science; Population Information Online (POPLINE); the WHO International Clinical Trials Registry Platform (WHO ICTRP); and the Global Health, Ovid and Health Management, ProQuest database. We performed searches until 30 June 2015 and supplemented these by searching revised bibliographies and by contacting experts to identify ongoing and unpublished studies.

SELECTION CRITERIA

We sought to include randomised controlled trials (RCTs) and controlled before-after (CBA) studies with at least two intervention and two control sites evaluating the generic IMCI strategy or its adaptation in children younger than age five, and including at minimum efforts to improve health care worker skills for case management. We excluded studies in which IMCI was accompanied by other interventions including conditional cash transfers, food supplementation, and employment. The comparison group received usual health services without provision of IMCI.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened searches, selected trials, and extracted, analysed and tabulated data. We used inverse variance for cluster trials and an intracluster co-efficient of 0.01 when adjustment had not been made in the primary study. We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach to assess the certainty of evidence.

MAIN RESULTS

Two cluster-randomised trials (India and Bangladesh) and two controlled before-after studies (Tanzania and India) met our inclusion criteria. Strategies included training of health care staff, management strengthening of health care systems (all four studies), and home visiting (two studies). The two studies from India included care packages targeting the neonatal period.One trial in Bangladesh estimated that child mortality may be 13% lower with IMCI, but the confidence interval (CI) included no effect (risk ratio (RR) 0.87, 95% CI 0.68 to 1.10; 5090 participants; low-certainty evidence). One CBA study in Tanzania gave almost identical estimates (RR 0.87, 95% CI 0.72 to 1.05; 1932 participants).One trial in India examined infant and neonatal mortality by implementing the integrated management of neonatal and childhood illness (IMNCI) strategy including post-natal home visits. Neonatal and infant mortality may be lower in the IMNCI group compared with the control group (infant mortality hazard ratio (HR) 0.85, 95% CI 0.77 to 0.94; neonatal mortality HR 0.91, 95% CI 0.80 to 1.03; one trial, 60,480 participants; low-certainty evidence).We estimated the effect of IMCI on any mortality measured by combining infant and child mortality in the one IMCI and the one IMNCI trial. Mortality may be reduced by IMCI (RR 0.85, 95% CI 0.78 to 0.93; two trials, 65,570 participants; low-certainty evidence).Two trials (India, Bangladesh) evaluated nutritional status and noted that there may be little or no effect on stunting (RR 0.94, 95% CI 0.84 to 1.06; 5242 participants, two trials; low-certainty evidence) and there is probably little or no effect on wasting (RR 1.04, 95% CI 0.87 to 1.25; two trials, 4288 participants; moderate-certainty evidence).The Tanzania CBA study showed similar results.Investigators measured quality of care by observing prescribing for common illnesses at health facilities (727 observations, two studies; very low-certainty evidence) and by observing prescribing by lay health care workers (1051 observations, three studies; very low-certainty evidence). We could not confirm a consistent effect on prescribing at health facilities or by lay health care workers, as certainty of the evidence was very low.For coverage of IMCI deliverables, we examined vaccine and vitamin A coverage, appropriate care seeking, and exclusive breast feeding. Two trials (India, Bangladesh) estimated vaccine coverage for measles and reported that there is probably little or no effect on measles vaccine coverage (RR 0.92, 95% CI 0.80 to 1.05; two trials, 4895 participants; moderate-certainty evidence), with similar effects seen in the Tanzania CBA study. Two studies measured the third dose of diphtheria, pertussis, and tetanus vaccine; and two measured vitamin A coverage, all providing little or no evidence of increased coverage with IMCI.Four studies (2 from India, and 1 each from Tanzania and Bangladesh) reported appropriate care seeking and derived information from careful questioning of mothers about recent illness. Some studies on effects of IMCI may report better care seeking behavior, but others do not report this.All four studies recorded maternal responses on exclusive breast feeding. They provided mixed results and very low-certainty evidence. Therefore, we do not know whether IMCI impacts exclusive breast feeding.No studies reported on the satisfaction of mothers and service users.

AUTHORS' CONCLUSIONS

The mix of interventions examined in research studies evaluating the IMCI strategy varies, and some studies include specific inputs to improve neonatal health. Most studies were conducted in South Asia. Implementing the integrated management of childhood illness strategy may reduce child mortality, and packages that include interventions for the neonatal period may reduce infant mortality. IMCI may have little or no effect on nutritional status and probably has little or no effect on vaccine coverage. Maternal care seeking behavior may be more appropriate with IMCI, but study results have been mixed, providing evidence of very low certainty about whether IMCI has effects on adherence to exclusive breast feeding.

Integrated Management of Childhood Illness (IMCI) Approach in management of Children with High Grade Fever ≥ 39°

BACKGROUND

Fever is one of the most frequently encountered pediatric problems, accounting for 25% of visits to pediatric emergency room. There is no specific standardized approach to reach to a final diagnosis in children with fever as this may be difficult and individualized for each child. The integrated management of childhood illness (IMCI) approach is an approach designed to reach a classification rather than a specific diagnosis.

OBJECTIVE

Comparison between IMCI and Non-IMCI approaches in management of children with high grade fever≥ 39°.

PATIENTS AND METHODS

This is a prospective study carried out on 50 children less than five years old presented with fever ≥ 39° attended the outpatient clinic of Minia university hospital from September 2012 to May 2014. These 50 children divided into 2 groups: group I (25 children) subjected to the (IMCI) approach and group II (25 children) subjected to the traditional approach.

RESULTS

Most of children according to the IMCI approach (64%) were classified and diagnosed during the first day, while most of children in traditional approach were diagnosed by the fourth (34%) or fifth day (20%). Sixty percent of children treated according to IMCI approach were improved clinically compared to 12% in traditional approach. Forty percent of children treated according to traditional approach had worse outcomes compared to 16% treated according to the IMCI.

CONCLUSION

The IMCI approach can be applied upon children under five years old with high grade fever to reach to a classification, early diagnosis, much better outcomes and less daily cost than the traditional approach.

Does integrated management of childhood illness (IMCI) training improve the skills of health workers? A systematic review and meta-analysis

Background

An estimated 6.9 million children die annually in low and middle-income countries because of treatable illneses including pneumonia, diarrhea, and malaria. To reduce morbidity and mortality, the Integrated Management of Childhood Illness strategy was developed, which included a component to strengthen the skills of health workers in identifying and managing these conditions. A systematic review and meta-analysis were conducted to determine whether IMCI training actually improves performance.

Methods

Database searches of CIHAHL, CENTRAL, EMBASE, Global Health, Medline, Ovid Healthstar, and PubMed were performed from 1990 to February 2013, and supplemented with grey literature searches and reviews of bibliographies. Studies were included if they compared the performance of IMCI and non-IMCI health workers in illness classification, prescription of medications, vaccinations, and counseling on nutrition and admistration of oral therapies. Dersminion-Laird random effect models were used to summarize the effect estimates.

Results

The systematic review and meta-analysis included 46 and 26 studies, respectively. Four cluster-randomized controlled trials, seven pre-post studies, and 15 cross-sectional studies were included. Findings were heterogeneous across performance domains with evidence of effect modification by health worker performance at baseline. Overall, IMCI-trained workers were more likely to correctly classify illnesses (RR = 1.93, 95% CI: 1.66–2.24). Studies of workers with lower baseline performance showed greater improvements in prescribing medications (RR = 3.08, 95% CI: 2.04–4.66), vaccinating children (RR = 3.45, 95% CI: 1.49–8.01), and counseling families on adequate nutrition (RR = 10.12, 95% CI: 6.03–16.99) and administering oral therapies (RR = 3.76, 95% CI: 2.30–6.13). Trends toward greater training benefits were observed in studies that were conducted in lower resource settings and reported greater supervision.

Conclusion

Findings suggest that IMCI training improves health worker performance. However, these estimates need to be interpreted cautiously given the observational nature of the studies and presence of heterogeneity.