Integrated management of childhood illness (IMCI) practice by trained health workers ( A baseline study)
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In Zambia, one in ten children dies before the first birthday, and one in five before their fifth birthday. To reduce this unacceptable high under five mortality the IMCI strategy was introduced in Zambia in 1995 by the Central Board of Health (CBOH) in collaboration with other cooperating partners, WHO, UNICEF and BASICS. The strategy combines improved management of childhood illness with aspects of nutrition, immunization, and several other important influences on child health, including maternal health. Using a set of interventions for the integrated treatment and prevention of major childhood illnesses, the IMCI strategy aims to reduce death and the frequency and severity of illness and disability, and to contribute to improved growth and development. This approach is calculated to be able to prevent up to 14% of the global burden of disease if appropriately applied in low-income countries.MCI training alone does not sustain improved health worker performance. Periodic evaluations coupled with feedback is essential for understanding the difficulties in the implementation and sustaining its effectiveness.The main objective of the study was to assess the knowledge and clinical performance of the health workers trained in IMCI with a view to identify operational difficulties and propose remedial measures to sustain the implementation of the IMCI strategy.The study was conducted in four districts(Chipata, Kafue, Kitwe and Luanshya) and among 38 IMCI trained health workers who attend to sick children in 30 health centres.Three checklists were used to observe and interview health workers managing 141 sick children aged two months up to five years presenting with at least any of the major IMCI targeted symptoms. Along with this, an inventory of facility infrastructure was undertaken to review the health facility on the availability of services and supplies.Besides the above, an interview was conducted with the health workers at the facilities to discuss supervision and the difficulties met in the implementation of IMCI.The study was conducted between November 25 and December 18,1998, by the Principal Investigator with the help of six health workers trained in IMCI based in Lusaka. The case management observation focused on the assessment of vital information, general danger signs, the major IMCI complaints, malnutrition and feeding assessment. 91(65%) out of 141 caretakers were asked whether the visit was initial or follow-up. 134(95%) and 125(89%) of the sick children who attended the facilities had their weight and temperature measured respectively due to non availability of the tools at some health facilities. Of the 141 sick children, 121(86.5%) were fully assessed for the presence of general danger signs. 86(92.2%) out of 107 children with the complaint of the cough or difficult breathing were fully assessed. Although 105 children presented with fever, only 65(62%) of them were fully assessed. The ear problem was well assessed in 79% of the children. 79(56%))children out of all the 141 who were seen in all the facilities had full assessment of malnutrition and anemia. Although 105 caretakers were breastfeeding, the health workers asked 68(65%) of them about the frequency of breastfeeding and other complementary foods. Despite most of the caretakers having received counseling, only 94(67%) of them were asked checking questions to confirm the understanding of instructions and advice given.Out of the 30 health facilities visited 10(30%) had no functioning refridgerators /cool box and sterilizers and did not offer immunization services daily. The distances between the nearest referral centre/hospital ranged from 2 to 60 kilometres. One third of health centres had no proper record keeping and most of the health facilities had shortages of IMCI recommended drugs. Although, almost every centre confirmed the visit by the Course Director or Facilitators after the IMCI training, the local DHMT's members visited only half of the facilities in their respective districts. The supervisors concentrated on facility review than observation of health workers managing sick children. Health workers from two thirds of the facilities received feedback from the DHMT supervisors during the visit. Majority of health workers trained in IMCI were able to assess the sick children correctly and communicate to their caretakers satisfactorily. Their performance was nevertheless affected by the non availability of basic tools, essential EMCI listed drugs, inadequate communication facilities and lack of supportive supervision.For the success of IMCI regular supervision, periodic evaluations of health worker performance in conjunction with feedback, and provision of essential drugs and supplies are necessary.
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