Barriers to implementation of the HIV guidelines in the IMCI algorithm among IMCI trained health workers in Zambia

Background  

Zambia adopted integrated management of Childhood illnesses (IMCI) in 1995 and a number of adaptations have been made to the generic WHO/UNICEF IMCI guidelines to better conform to Zambia's health service needs. One significant adaptation is the incorporation of HIV guidelines into the IMCI algorithm. Since 2004, health workers that have undergone IMCI case management training have also received training in HIV assessment. During initial follow-up visits in 11 districts 90 health workers were assessed in 2007 to determine their adherence to the IMCI algorithm. The assessment showed that 97% of the health workers assessed did not review or mention the HIV guidelines even though they had received HIV training as part of IMCI. This study aimed to explore reasons for non-adherence to HIV guidelines in the IMCI algorithm and make recommendations on how this can be improved.     

Integrated management of childhood illness (IMCI) follow-up of basic health workers

Objective: To assess the practice of skills learnt by basic health workers for 4 — 2 — 8 weeks and one year after IMCI training, and to identify the gaps in practices due to various constraints.Methods : Theanganwadi workers (AWWS) and the supervisory staff were given 5 days IMCI training using WHO package. The supervisors gave follow up visits to AWWs using standardized follow up forms adapted from WHO material. The supervisors gave follow up visit to the 1^st batch of AWWs 1 year after training in IMCI and a second visit was given 4–8 weeks after the 1^st visit. The 2^nd batch of AWWs was followed up 4–8 weeks after training in IMCI.Results : The performance on correct treatment of cases by AWWs weeks were trained 4 — 2 — 6 weeks prior to follow up was better than group followed up one year after the completion of training (81.8% and 47.9% respectively). At the same time, the performance on correct treatment showed significant improvement during the second follow up (47.9% and 83.8% respectively). Performance on counseling improved from 15.6% during 1^st follow up to 52.1 % during 2^nd follow up visit. The average number of cases seen by AWWs increased from 6.6 in 1^st follow up to 9.3 during second follow up of the same AWWs.Conclusion: The basic health workers (AWWs) are capable of correct case management of sick children using the IMCI guidelines. The first follow up visit should not be delayed as delay leads to loss of skills. The health workers benefit from frequent and regular follow up by supervisors. Provision of requisite supplies is essential for practice of skills after training in IMCI by basic health worker.     

Child mortality rates in rural India: an experience from the Ballabgarh project

In a special project area of rural India, the age-specific mortality rates of a birth cohort 0-59 months old were calculated from 1991 to 1999. The mortality rates were lower than the national average, but the common causes of child deaths were similar. Since 1985, when the Universal Immunization Programme of India introduced routine measles vaccination, there has been a proportionate decline in child deaths unlike other parts of India. The absolute numbers of child deaths from 'all' causes have also declined significantly over the same period of time. The vaccination coverage in the project area is higher than the national average. This suggests a possible 'beneficial' non-specific effect of measles vaccination on child survival over this time period.     

Comprehensive rural health services project Ballabgarh : trends in underfive mortality

Mortality data of underfives during 1972–1974 and 1982–1984 in rural area were analysed. Underfives’ deaths were reduced by 35.9%, though the reduction was less in infants (27.2%), than in post infancy underfives (46.9%). The underfives’ death rate came down by 44.1% (from 38.3) to21.4 per 1000 underfives during the decade. The infant deaths show a uniform reduction in different age periods. The female underfives’ deaths are more than male deaths indicating a relative neglect of female children. The only diseases showing reduction in mortality in a substantial manner are tetanus and typhoid. Otherwise there is a general reduction in all causes. Prematurity, acute respiratory infections, diarrhoeal diseases, malnutrition and septicemia constituted 84.7% of deaths in infancy in 1982–84 and acute respiratory infections, malnutrition and diarrheal diseases constituted 69.7% in the 1–4 age group. This study shows how a strong referral service built into medical care with preventive and promotive methods can reduce the underfives mortality.     

Use of verbal autopsy by health workers in under-five children

We conducted this study to ascertain whether health workers can routinely administer verbal autopsy (VA) to determine the cause of death in their area. The health workers were trained to administer verbal autopsy tool on the deaths occurring in the population under them. All the verbal autopsies of under-five deaths between January 2000 to December 2001 were reviewed by a pediatrician. There were 262 deaths of children under five years in this period, and 71% of them were infants, out of which 34% were neonatal deaths. The health workers reported PEM, fever, pneumonia, and diarrhea as the leading causes of death, based on the existing system of obtaining information provided by the family members. Verbal autopsy forms reviewed by a pediatrician also showed that apart from fever, the first three causes of death were the same i.e., PEM, diarrhea and pneumonia. This study shows that health workers can be trained to use the verbal autopsy to ascertain the cause of death.     

Transfer of sick children by air

The annual growth rate of air traffic is increasing at the rate of about 7% all over the world. Children and adolescents make a significant chunk of travelling population. Some of the neonates too take to civil air and travel under various circumstances. Others travel for the reasons of medical air evacuation and better treatment at some specialized tertiary care centers, within India or abroad or simply as medical emergency. With the increasing availability of air taxis and air ambulances, it has become necessary for the pediatricians to know the consequences and potential hazards of transfer of the sick by air, lest they lose their patients unintentionally despite professional proficiency. Air evacuation of sick child is a highly specialized job, much different from an evacuation by any fast car ambulance. The paper discusses the general impact of aviation stresses in civil aviation with special reference to sick neonates, children and adolescents, and provides general guidelines, which could be applied to any particular clinical condition with knowledge of underlying physiological processes and anticipated alterations in cabin environment. It also brings out the issues of proper pre-flight assessment, fitness to undertake air transfer, general handling of patient under transfer, desirable onboard procedures, do s and don ts during air transfer, limitations of conventional neonatal/child resuscitation kits, available medical support in aircraft cabins, proper use of hardware including physiology monitoring systems, permissible specialized medical aids, and the requirement and use of equipment during air evacuation. The importance of high awareness and preventive measures is reiterated.     

Primary health care for Hispanic children of migrant farm workers.

Providing primary care to children of culturally diverse populations is a challenge for pediatric nurse practitioners and educators. The challenge is intensified when providing care to Hispanic children who are uprooted because their parent(s) are migrant farm workers. The creation of health-focused academic community partnerships is one unique strategy to improve primary care to these children. One such partnership is the ongoing Migrant Family Health Program in which practitioner nursing students and their faculty members provide primary health care to children who are enrolled in a summer education program for migrant children.     

Integrated Management of Childhood Illness (IMCI) : A robust strategy

Integrated Management of Childhood Illness (IMCI), a strategy fostering holistic approach to child health and development, is built upon successful experiences gained from effective child health interventions like immunization, oral rehydration therapy, management of acute respiratory infections and improved infant feeding. The core intervention of IMCI is integrated management of the five most important causes of childhood deaths-acute respiratory infections, diarrheal diseases, measles, malaria and malnutrition. Using a set of interventions for the integrated treatment and prevention of major childhood illnesses, the IMCI strategy aims to reduce death as well as the frequency and severity of illness and disability, thus contributing to improved growth and development. In health facilities, the IMCI strategy promotes the accurate identification of childhood illness (es) in the outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers and the provision of preventive services, and speeds up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. It also creates a scientifically sound link between the management guidelines at the community level and the management approach in a referral centre. The strategy also envisages actual situations when referral is not possible and offers the best possible options in such circumstances. In the home setting, it promotes appropriate early home care and care-seeking, improved nutrition and prevention, and the correct implementation of prescribed care. In addition to its focus on treatment of illness in the health facility as well as at home, it also provides an opportunity for important preventive interventions such as immunization and improved infant and child nutrition including breastfeeding. The IMCI strategy reduces wastage of resources and avoids duplication of efforts that may occur in a series of separate disease control programs. The essential pillars include improvement in the case management skills of health personnel, improvement in health systems, and improvement in family and community practices. IMCI has been introduced in more than 80 countries and 19 of them have already scaled up IMCI implimentation Even though it is too early to relate the decrease in childhood mortality with the introduction of IMCI inthese countries, there are several indirect indicators which endorse its validity as a comprehensive and effective strategy. IMCI has helped countries to revise and update their child health policies, streamline the essential drug lists for children, increase service utilization, improve quality of care and nutritional counselling, improve health systems and improved family and community practices.     

Experiences of training and implementation of integrated management of childhood illness (IMCI) in South Africa: a qualitative evaluation of the IMCI case management training course

Background  

Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under-5 years by improving management of common illnesses at primary level. IMCI has been shown to improve health worker performance, but constraints have been identified in achieving sufficient coverage to improve child survival, and implementation remains sub-optimal. At the core of the IMCI strategy is a clinical guideline whereby health workers use a series of algorithms to assess and manage a sick child, and give counselling to carers. IMCI is taught using a structured 11-day training course that combines classroom work with clinical practise; a variety of training techniques are used, supported by comprehensive training materials and detailed instructions for facilitators.     

Triage decisions in child care for sick children

Child-care centers for children with mild, acute communicable, and noncommunicable illnesses are beginning to evolve. Few states have enacted regulations concerning the policies and procedures under which child-care centers for sick children operate. These centers should have policies regarding the triage and care of ill children that promote the safety of all children and staff at the center. As part of the establishment of regulations for the Michigan Department of Social Services, Lansing, a triage model has been developed that provides a means of standardizing the screening process used to admit mildly ill children to such centers. We present pilot guidelines for use by center personnel, discuss considerations inherent in formulating triage policy for child-care centers for sick children, and provide a starting point for those attempting to standardize regulations governing child-care centers for sick children.     

Innovative programmes of medical education: II. Commentary and lessons for India

Major areas in which innovative approaches in medical education have been tried include student selection, learning strategies, and community orientation. It is relatively easier to implement innovations in a new institution. In established medical schools, running two simultaneous curricula tracks, the traditional and the innovative has emerged as a popular strategy for introducing new systems of education. Institutional commitment to the objectives and matching implementation effort determine the success of an innovative programme. Stronger links between the medical education and health service systems not only enhance the community orientation of the graduates, but also help improve the quality of health care provided to the community. There is a need to experiment with innovative approaches to education of physicians in our country. Establishment of medical education units in medical schools will be a practical beginning in the right direction.     

Design and implementation of injury prevention curricula for elementary schools: lessons learned

OBJECTIVES: Project objectives were to: (1) design and produce an easy-to-use, replicable comprehensive injury prevention curriculum for elementary schools; (2) pilot the program to determine instructors' ease in teaching the material and its usefulness in enhancing student knowledge and behavior change; (3) present material in subject-integrated, grade-specific lessons that would meet state and national student learning objectives; and (4) submit and obtain adoption of the curriculum by the State Department of Education. METHODS: A pilot program was developed, implemented, and evaluated in six intervention and six control schools. The curriculum was revised and implemented in five other schools and finalized according to evaluation results and teachers' and parents' suggestions. Community resources such as police, fire, and county health departments participated in program implementation. RESULTS: The program showed a significant increase from 21% to 36% in seatbelt use during the school year in program schools compared with a 1% decrease in control schools. Bicycle helmet use increased from 0% to 10% in the program schools. Pre-test and post-test results showed significant differences in student knowledge, attitudes, and behaviors within the program schools, and in comparing the program and control schools. On a Likert scale of 1 (poor) to 7 (excellent), teachers rated lesson content, exercises, and the usefulness of materials and resources as 5.8, 5.5, and 5.4, respectively. Evaluations for the revised curricula ranged from 5.7 to 6.2. CONCLUSIONS: The favorable evaluation results resulted in the adoption of the curriculum as a state textbook, and widespread teaching of the curriculum. The product is appropriate and efficacious in these elementary schools and their communities.     

Utility of telemedicine for children in India

Objective  

To show utility of telemedicine to children in Indian subcontinent.