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

<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>We conducted focus group discussions with IMCI trained health workers to explore their experiences of the methodology and content of the IMCI training course, whether they thought they gained the skills required for implementation, and their experiences of follow-up visits.</p> <p>Results</p> <p>Health workers found the training interesting, informative and empowering, and there was consensus that it improved their skills in managing sick children. They appreciated the variety of learning methods employed, and felt that repetition was important to reinforce knowledge and skills. Facilitators were rated highly for their knowledge and commitment, as well as their ability to identify problems and help participants as required. However, health workers felt strongly that the training time was too short to acquire skills in all areas of IMCI. Their increased confidence in managing sick children was identified by health workers as an enabling factor for IMCI implementation in the workplace, but additional time required for IMCI consultations was expressed as a major barrier. Although follow-up visits were described as very helpful, these were often delayed and there was no ongoing clinical supervision.</p> <p>Conclusion</p> <p>The IMCI training course was reported to be an effective method of acquiring skills, but more time is required, either during the course, or with follow-up, to improve IMCI implementation. Innovative solutions may be required to ensure that adequate skills are acquired and maintained.</p

Clinical assessment of speech correlates well with lung function during induced bronchoconstriction

Clinical assessment of asthma often includes a crude assessment of speech, for example whether the patient can speak in full sentences. To date, this statement, despite appearing in national asthma guidelines, has not been related to lung function testing in asthma exacerbation. Seven asthmatics underwent a bronchial challenge and were then recorded reading a standardised text for 1?min. The recordings were played to 88 healthcare professionals who were asked to estimate FEV1% predicted. Health care professionals' estimations showed moderate correlation to FEV1% predicted (rho=0.61 P&lt;0.01). There were no significant differences between professionals grouped by seniority or speciality. Speech can intuitively be estimated by health care professionals with moderate accuracy. This gives an evidence basis for the assessment in speech in acute asthma and may provide a new avenue for monitorin

Nasal nitric oxide screening for primary ciliary dyskinesia: systematic review and meta-analysis

Nasal nitric oxide (nNO) concentrations are low in patients with primary ciliary dyskinesia (PCD) providing a noninvasive screening test. We conducted a systematic review of the literature to examine the utility of nNO in screening for PCD, in particular 1) different respiratory manoeuvres during sampling (velum closure, tidal breathing, etc.), 2) accuracy in screening young/uncooperative children, 3) stationary versus portable analysers, and 4) nNO in "atypical" PCD. 96 papers were assessed according to modified PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and 22 were included in this review. Meta-analysis of 11 studies comparing nNO during a velum closure breath hold gave a mean±sd nNO of 19.4±18.6 nL·min(-1) in PCD (n = 478) and 265.0±118.9 nL·min(-1) in healthy controls (n = 338). Weighted mean difference for PCD versus healthy controls was 231.1 nL·min(-1) (95% CI 193.3-268.9; n = 338) and 114.1 nL·min(-1) (95% CI 101.5-126.8; n = 415) for PCD versus cystic fibrosis. Five studies of nNO measurement during tidal breathing demonstrated that this is an acceptable manoeuvre in young children where velum closure is not possible, but the discriminatory value was reduced. Four small studies of portable NO analysers suggest these are reliable tools for screening for PCD. However, nNO must be interpreted alongside clinical suspicion. Future studies should focus on standardising sampling techniques and reporting

The dangers of widespread nitric oxide screening for primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) is underdiagnosed and requires complex testing at specialist diagnostic centres. Measurement of nasal nitric oxide (nNO) has good sensitivity and specificity screening for PCD, but is currently usually measured at PCD centres rather than prior to referral. Proposals to include NO testing for asthma diagnoses could widen access to PCD screening if nasal mode analysers are available. Data from 282 consecutive referrals to our PCD diagnostic centre (31 PCD positive) were used to model predictive values for nNO testing with varying pretest probability and showed that predictive values were good in the referral population, but extending screening to more general populations would result in excessive false positives that may overwhelm diagnostic services. Although nNO remains a useful test, a 'normal' result with classical clinical history should still be considered for further testing

Systematic review of evidence for relationships between physiological and CT indices of small airways and clinical outcomes in COPD

Background: small airways disease (SAD) is considered pivotal in the pathology of COPD. There are numerous publications describing physiological and Computed Tomography (CT) imaging markers to detect SAD. However, there is no agreed gold standard and limited understanding of the clinical associations of these measures to disease outcomes.Methods: we conducted a systematic review using Embase, Medline and Pubmed to explore the relationship between physiological and CT SAD measures in COPD (GOLD Stages 1–4). Furthermore, evidence linking these physiological measures with defined clinical outcomes such as health status, functional assessment and exacerbation frequency were summarised.Results: the search yielded 1160 abstracts of which 19 met the search criteria. Six studies examined physiological and CT measures while 13 publications identified physiological measures and clinical outcomes. Strong correlations were seen between CT and physiological measures of SAD. Varying associations between physiological measures and defined clinical outcomes were noted.Conclusions: physiological and CT measures of SAD correlate and infer similar information. Physiological measures of SAD may offer valuable insight into clinical expression of the disease. A consensus on the standardisation and recommendation of tests to measure SAD is needed in order to better understand any clinical benefits of targeted drug therapy to the small airways

Assessment of small airways dysfunction with impulse oscillometry, multiple flow nitric oxide and spirometry in the Wessex severe asthma cohort study

Rationale: Asthma is a disease of the conducting airways. Small airway events are poorly reflected by standard lung function. Methods: IOS, spirometry and FeNO measures were made in healthy controls (HC, n=76), non-steroid treated mild asthmatics (MA, n=30), steroid treated step 2/3 asthmatics (ModA, n=35) and treatment-resistant step4/5 severe asthmatics (SA n=71), to assess disease related small airways dysfunction. Group comparisons and correlations were undertaken using both parametric and non-parametric statistical analyses. Results: Maximum airway nitric oxide flux (JawNO) , reflecting central airways inflammation, was increased in MA (median 2740, p&lt;0.001) compared to both HC (640)and SA (700). By contrast, alveolar nitric oxide (CANO), which reflects peripheral airway inflammation, was significantly increased in all asthma groups compared to HC (p&lt;0.05). Increased peripheral resistance was significantly elevated in asthma (p&lt;0.001), with R5-R20&gt;10% in absolute values being present in 53.3% of MA, 74.3% of ModA and 84.5% of SA.. A significant negative correlation was noted between R5-R20 and MEF25-75(r=-0.537), p&lt;0.001),and both parameters correlated with asthma control ACQ6 (p&lt;0.001) and asthma quality of life (p&lt;0.001). Conclusion: Increased small airways resistance and distal inflammation is a feature of asthma with increasing peripheral resistance with disease severity. In SA this is associated with worse asthma control and greater impairment in quality of life. These findings emphasise the importance of the small airways to disease pathophysiology in asthma

The Wessex AsThma CoHort (WATCH) difficult asthma study: integrating research into the clinic

The WATCH Study is a longitudinal study of patients under the Difficult Asthma Clinic at University Hospital Southampton, UK. To create a better real life understanding of difficult asthma (British Thoracic Society (BTS) step 4/5), a process of clinical dataset compilation, meeting clinical and research needs, was adopted.One objective was to trial feasibility of longitudinal data collection in a large outpatient clinic cohort. Other aims included;a) Merging research and clinical objectives; meeting needs of the BTS Difficult Asthma registry plus data collation needed for research purposesb) Ensuring all eligible patients have the opportunity to participate in research, current and future.c) Gathering all relevant clinical data to support clinical phenotypingd) Ensuring data was collected in a time efficient mannerFigure1Download figure | Open in new tab | Download powerpointNumber of patients recruited to date (175). Recruitment rate (18.2 per month). Total recruitment failures; due to lack of asthma severity (10). Number declining participation (8). Number withdrawn (1) (no reason given).Using a method combining clinical and research services to collect longitudinal data from this large cohort of patients attending the Difficult Asthma clinic was feasible and successful. The majority of patients approached were consented, participated and stayed in the study.<br/

Impact of the Wessex AsThma CoHort (WATCH) study on recruitment to research

WATCH is a longitudinal observational study of patients under the Difficult Asthma Clinic at University Hospital Southampton (UHS), UK. Enhanced asthma phenotyping in the study helps improve patient care, as well as identifying patients suitable for research. These patients may otherwise be missed due to divide between clinical and research goals.One objective was to measure the impact of large outpatient cohort recruitment on patient enrolment rates in asthma research.Method: Adult Severe asthmatics (British Thoracic Society (BTS) step 4 or 5) were recruited from the Difficult Asthma clinic at UHS. Monthly recruitment numbers are shown for adult severe asthmatics PreWATCH (Jun 2014-Dec 2014) and PostWATCH (Jun 2015-Dec 2015).Figure1Download figure | Open in new tab | Download powerpointResults: Total number of patients recruited PreWATCH was 21. Total number of patients recruited in PostWATCH group was 201. This includes patients recruited to WATCH itself (n=161) but also those recruited to non-WATCH adult severe asthma studies (n=40). Percentage improvement in recruitment PostWATCH was 47.5%. Overall improvement in recruitment (including WATCH) was 111.67%.Conclusion: Preliminary analysis suggests improvement to overall recruitment following commencement of WATCH. Further planned analysis will include qualitative questionnaires, and will hopefully show both positive impact on recruitment rates, as well as improvements to patient care and clinic/research experience.<br/