Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan

Background Integrated management of childhood illnesses (IMCI) strategy has been proven to improve health outcomes in children under 5 years of age. Pakistan, despite being in the late implementation phase of the strategy, continues to report high under-five mortality due to pneumonia, diarrhea, measles, and malnutrition - the main targets of the strategy. Objective The study determines the factors influencing IMCI implementation at public-sector primary health care (PHC) facilities in Matiari district, Sindh, Pakistan. Design An exploratory qualitative study with an embedded quantitative strand was conducted. The qualitative part included 16 in-depth interviews (IDIs) with stakeholders which included planners and policy makers at a provincial level (n=5), implementers and managers at a district level (n=3), and IMCI-trained physicians posted at PHC facilities (n=8). Quantitative part included PHC facility survey (n=16) utilizing WHO health facility assessment tool to assess availability of IMCI essential drugs, supplies, and equipments. Qualitative content analysis was used to interpret the textual information, whereas descriptive frequencies were calculated for health facility survey data. Results The major factors reported to enhance IMCI implementation were knowledge and perception about the strategy and need for separate clinic for children aged under 5 years as potential support factors. The latter can facilitate in strategy implementation through allocated workforce and required equipments and supplies. Constraint factors mainly included lack of clear understanding of the strategy, poor planning for IMCI implementation, ambiguity in defined roles and responsibilities among stakeholders, and insufficient essential supplies and drugs at PHC centers. The latter was further substantiated through health facilities\u27 survey findings, which indicated that none of the facilities had 100% stock of essential supplies and drugs. Only one out of all 16 surveyed facilities had 75% of the total supplies, while 4 out of 16 facilities had 56% of the required IMCI drug stock. The mean availability of supplies ranged from 36.6 to 66%, while the mean availability of drugs ranged from 45.8 to 56.7%. Conclusion Our findings indicate that the Matiari district has sound implementation potential; however, bottlenecks at health care facility and at health care management level have badly constrained the implementation process. An interdependency exists among the constraining factors, such as lack of sound planning resulting in unclear understanding of the strategy; leading to ambiguous roles and responsibilities among stakeholders which manifest as inadequate availability of supplies and drugs at PHC facilities. Addressing these barriers is likely to have a cumulative effect on facilitating IMCI implementation. On the basis of these findings, we recommend that the provincial Ministry of Health (MoH) and provincial Maternal Neonatal and Child Health (MNCH) program jointly assess the situation and streamline IMCI implementation in the district through sound planning, training, supervision, and logistic support

Die Amsterdam Preoperative Anxiety and Information Scale (APAIS) - erste Erprobung einer deutschsprachigen Version

Objective: Preoperative anxiety influences the result of the treatment in patients. To assess preoperative anxiety the Amsterdam Preoperative Anxiety and Information Scale (APAIS) was developed. The APAIS measures anxiety and the need-for-information with 6 items, with good reliability and validity. This article presents the first test of the German version of this screening instrument.Methods: The German version of the APAIS was tested on 68 patients questioned before surgery on the lower extremities in the Orthopaedic Department of a University Hospital. From 68 patients, 47 (69%) were female and the average age was 55 years. Besides the APAIS, several additional questionnaires with similar or divergent content were administered for testing the convergent and discriminant validity of the APAIS (HADS, SCL-9-K, KASA, COSS, STOA).Results: The two scales anxiety and need-for-information could be replicated by a factor analysis and had high reliability (anxiety: Cronbachs Alpha = 0.92; need-for-information: Cronbachs Alpha = 0.86). As expected the scales of the APAIS correlated highly with different standard questionnaires which measure anxiety (KASA, STOA) and low with questionnaires of divergent contents (HADS depression, COSS). The APAIS-scales are independent of sex, age or previous surgeries. Patients with a higher need-for-information show higher anxiety (r=0.59) prior to surgery.Conclusions: During its first trial the German version of the APAIS proved to be a reliable and valid instrument. Furthermore, it is a good screening instrument to assess preoperative anxiety and need-for-information in clinical practice, especially due to its brevity. In further studies the predictive validity has to be examined in large heterogeneous samples.Zielsetzung: Das präoperative Angstniveau eines Patienten kann entscheidenden Einfluss auf das Behandlungsergebnis haben. Zur Erfassung präoperativer Angst wurde 1996 die Amsterdam Preoperative Anxiety and Information Scale (APAIS) vorgestellt. Dieses Instrument soll die Skalen "Angst vor Anästhesie und Operation" und "Informationsbedürfnis" mit nur sechs Items valide und reliabel erfassen. Dargestellt wird die erste Überprüfung einer deutschen Version dieses Screeninginstruments.Methodik: Die Erprobung erfolgte an 68 Patienten einer orthopädischen Universitätsklinik vor einer Operation an den unteren Extremitäten. 47 (69%) waren weiblich, das Durchschnittsalter betrug 55 Jahre. Zur Prüfung der konvergenten und diskriminanten Validität wurden weitere inhaltsähnliche bzw. -fremde Fragebogenverfahren eingesetzt (HADS, SCL-9-K, KASA, COSS, STOA).Ergebnisse: In der Faktorenanalyse konnten die beiden Skalen repliziert werden. Sie besitzen eine hohe Reliabilität (Angst: Cronbachs Alpha = 0,92; Informationsbedürfnis: Cronbachs Alpha = 0,86). Die Skalen der APAIS korrelieren erwartungsgemäß hoch mit anderen spezifischen Angstfragebögen (KASA, STOA) und niedriger mit inhaltsferneren Verfahren (HADS Depressivität, COSS). Die APAIS-Skalen sind nicht abhängig von Geschlecht, Alter oder bisherigen Operationserfahrungen. Patienten mit einem höheren Informationsbedürfnis haben auch ein höheres Angstniveau (r=0,59).Fazit: In der ersten Erprobung erwies sich die deutsche Version der APAIS als reliables und valides Instrument, das aufgrund seiner Kürze sehr gut zum Screening von präoperativer Angst und Informationsbedürfnis im klinischen Alltag geeignet ist. Weitere Studien, insbesondere zur prädiktiven Validität, müssen an umfangreicheren, heterogeneren Stichproben erfolgen