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

ABSTRACT: 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.

SUBMITTER: Renosa MD

PROVIDER: S-EPMC7067189 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:IntroductionDespite the evidence for preventing childhood morbidity and mortality, financial resources are cited as a constraint for Governments to scale up the key health interventions in some countries. We evaluate the cost effectiveness of implementing IMNCI program in India from a health system and societal perspective.MethodsWe parameterized a decision analytic model to assess incremental cost effectiveness of IMNCI program as against routine child health services for infant population at district level in India. Using a 15-years time horizon from 2007 to 2022, we populated the model using data on costs and effects as found from a cluster-randomized trial to assess effectiveness of IMNCI program in Haryana state. Effectiveness was estimated as reduction in infant illness episodes, deaths and disability adjusted life years (DALY). Incremental cost per DALY averted was used to estimate cost effectiveness of IMNCI. Future costs and effects were discounted at a rate of 3%. Probabilistic sensitivity analysis was undertaken to estimate the probability of IMNCI to be cost effective at varying willingness to pay thresholds.ResultsImplementation of IMNCI results in a cumulative reduction of 57,384 illness episodes, 2369 deaths and 76,158 DALYs among infants at district level from 2007 to 2022. Overall, from a health system perspective, IMNCI program incurs an incremental cost of USD 34.5 (INR 1554) per DALY averted, USD 34.5 (INR 1554) per life year gained, USD 1110 (INR 49,963) per infant death averted. There is 90% probability for ICER to be cost effective at INR 2300 willingness to pay, which is 5.5% of India's GDP per capita. From a societal perspective, IMNCI program incurs an additional cost of USD 24.1 (INR 1082) per DALY averted, USD 773 (INR 34799) per infant death averted and USD 26.3 (INR 1183) per illness averted in during infancy.ConclusionIMNCI program in Indian context is very cost effective and should be scaled-up as a major child survival strategy.

Project description:BackgroundThe introduction of the WHO's Integrated Management of Childhood Illnesses (IMCI) guidelines in the mid-1990s contributed to global reductions in under-five mortality. However, issues in quality of care have been reported. We aimed to determine resource availability and healthcare worker knowledge of IMCI guidelines in two districts in Malawi.MethodsWe conducted a mixed-methods study, including health facility audits to record availability and functionality of essential IMCI equipment and availability of IMCI drugs, healthcare provider survey and focus group discussions (FGDs) with facility staff. The study was conducted between January and April 2019 in Mchinji (central region) and Zomba (southern region) districts. Quantitative data were described using proportions and χ2 tests; linear regression was conducted to explore factors associated with IMCI knowledge. Qualitative data were analysed using a pragmatic framework approach. Qualitative and quantitative data were analysed and presented separately.ResultsForty-seven health facilities and 531 healthcare workers were included. Lumefantrine-Artemether and cotrimoxazole were the most available drugs (98% and 96%); while amoxicillin tablets and salbutamol nebuliser solution were the least available (28% and 36%). Respiratory rate timers were the least available piece of equipment, with only 8 (17%) facilities having a functional device. The mean IMCI knowledge score was 3.96 out of 10, and there was a statistically significant association between knowledge and having received refresher training (coeff: 0.42; 95% CI 0.01 to 0.82). Four themes were identified in the FGDs: IMCI implementation and practice, barriers to IMCI, benefits of IMCI and sustainability.ConclusionWe found key gaps in IMCI implementation; however, these were not homogenous across facilities, suggesting opportunities to learn from locally adapted IMCI best practices. Improving on-going mentorship, training and supervision should be explored to improve quality of care, and programming which moves away from vertical financing with short-term support, to a more holistic approach with embedded sustainability may address the balance of resources for different conditions.

Project description:BACKGROUND: Curative interventions delivered by community health workers (CHWs) were introduced to increase access to health services for children less than five years and have previously targeted single illnesses. However, CHWs in the integrated community case management of childhood illnesses strategy adopted in Uganda in 2010 will manage multiple illnesses. There is little documentation about the performance of CHWs in the management of multiple illnesses. This study compared the performance of CHWs managing malaria and pneumonia with performance of CHWs managing malaria alone in eastern Uganda and the factors influencing performance. METHODS: A mixed methods study was conducted among 125 CHWs providing either dual malaria and pneumonia management or malaria management alone for children aged four to 59 months. Performance was assessed using knowledge tests, case scenarios of sick children, review of CHWs' registers, and observation of CHWs in the dual management arm assessing respiratory symptoms. Four focus group discussions with CHWs were also conducted. RESULTS: CHWs in the dual- and single-illness management arms had similar performance with respect to: overall knowledge of malaria (dual 72%, single 70%); eliciting malaria signs and symptoms (50% in both groups); prescribing anti-malarials based on case scenarios (82% dual, 80% single); and correct prescription of anti-malarials from record reviews (dual 99%, single 100%). In the dual-illness arm, scores for malaria and pneumonia differed on overall knowledge (72% vs 40%, p < 0.001); and correct doses of medicines from records (100% vs 96%, p < 0.001). According to records, 82% of the children with fast breathing had received an antibiotic. From observations 49% of CHWs counted respiratory rates within five breaths of the physician (gold standard) and 75% correctly classified the children. The factors perceived to influence CHWs' performance were: community support and confidence, continued training, availability of drugs and other necessary supplies, and cooperation from formal health workers. CONCLUSION: CHWs providing dual-illness management handled malaria cases as well as CHWs providing single-illness management, and also performed reasonably well in the management of pneumonia. With appropriate training that emphasizes pneumonia assessment, adequate supervision, and provision of drugs and necessary supplies, CHWs can provide integrated treatment for malaria and pneumonia.

Project description:BackgroundAn 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.MethodsDatabase 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.ResultsThe 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.ConclusionFindings 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.

Project description:ObjectiveTo assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries.SettingThe 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).MethodsWe 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.ParticipantsIn-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef.ResultsEighty-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).ConclusionThis 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.

Project description:BackgroundThe Strategy of the Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, the misuse of antibiotics, polypharmacy and over-hospitalization of children. A study carried out in 16 countries analysed the status and strengths of as well as the barriers to IMCI implementation and investigated how different health systems affect the problems IMCI aims to address. Here we present findings in relation to IMCI's effects on the rational use of drugs, particularly the improved rational use of antibiotics in children, the mechanisms through which these were achieved as well as counteracting system factors.Methods220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data was analysed for arising themes and peer-reviewed.ResultsThe implementation of IMCI led to improved prescribing patterns immediately after training of health workers according to key informants. IMCI provides standard treatment guidelines and an algorithmic diagnostic- and treatment-decision-tool for consistent decision-making. Doctors reported feeling empowered by the training to counsel parents and address their expectations and desire for invasive treatments and the use of multiple drugs. Improved prescribing patterns were not sustained over time but counteracted by factors such as: doctors prescribing antibiotics to create additional revenues or other benefits; aggressive marketing by pharmaceutical companies; parents pressuring doctors to prescribe antibiotics; and access to drugs without prescriptions.ConclusionsFuture efforts to improve child health outcomes must include: (1) the continued support to improve health worker performance to enable them to adhere to evidence-based treatment guidelines, (2) patient and parent education, (3) improved reimbursement schemes and prescription regulations and their consistent enforcement and (4) the integration of point-of-care tests differentiating between viral and bacterial infection into standards of care. Pre-requisites will be sufficient remuneration of health workers, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.

Project description:BACKGROUND:Meningococcal serogroup A conjugate vaccine (MACV) was introduced in 2017 into the routine childhood immunization schedule (at 15-18?months of age) in Burkina Faso to help reduce meningococcal meningitis burden. MACV was scheduled to be co-administered with the second dose of measles-containing vaccine (MCV2), a vaccine already in the national schedule. One year following the introduction of MACV, an assessment was conducted to qualitatively examine health workers' perceptions of MACV introduction, identify barriers to uptake, and explore opportunities to improve coverage. METHODS:Twelve in-depth interviews were conducted with different cadres of health workers in four purposively selected districts in Burkina Faso. Districts were selected to include urban and rural areas as well as high and low MCV2 coverage areas. Respondents included health workers at the following levels: regional health managers (n?=?4), district health managers (n?=?4), and frontline healthcare providers (n?=?4). All interviews were recorded, transcribed, and thematically analyzed using qualitative content analysis. RESULTS:Four themes emerged around supply and health systems barriers, demand-related barriers, specific challenges related to MACV and MCV2 co-administration, and motivations and efforts to improve vaccination coverage. Supply and health systems barriers included aging cold chain equipment, staff shortages, overworked and poorly trained staff, insufficient supplies and financial resources, and challenges with implementing community outreach activities. Health workers largely viewed MACV introduction as a source of motivation for caregivers to bring their children for the 15- to 18-month visit. However, they also pointed to demand barriers, including cultural practices that sometimes discourage vaccination, misconceptions about vaccines, and religious beliefs. Challenges in co-administering MACV and MCV2 were mainly related to reluctance among health workers to open multi-dose vials unless enough children were present to avoid wastage. CONCLUSIONS:To improve effective administration of vaccines in the second-year of life, adequate operational and programmatic planning, training, communication, and monitoring are necessary. Moreover, clear policy communication is needed to help ensure that health workers do not refrain from opening multi-dose vials for small numbers of children.

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

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