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

Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study

<p>Abstract</p> <p>Background</p> <p>Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. Most public health interventions in Uganda have addressed only selected supply side issues, and universities have focused their efforts on providing maternal services at tertiary hospitals. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders.</p> <p>Methods</p> <p>This quasi-experimental trial is conducted in two districts in Eastern Uganda. The supply side component includes health worker refresher training and additions of minimal drugs and supplies, whereas the demand side component involves vouchers given to pregnant women for motorcycle transport and the payment to service providers for antenatal, delivery, and postnatal care. The trial is ongoing, but early analysis from routine health information systems on the number of services used is presented.</p> <p>Results</p> <p>Motorcyclists in the community organized themselves to accept vouchers in exchange for transport for antenatal care, deliveries and postnatal care, and have become actively involved in ensuring that women obtain care. Increases in antenatal, delivery, and postnatal care were demonstrated, with the number of safe deliveries in the intervention area immediately jumping from <200 deliveries/month to over 500 deliveries/month in the intervention arm. Voucher revenues have been used to obtain needed supplies to improve quality and to pay health workers, ensuring their availability at a time when workloads are increasing.</p> <p>Conclusions</p> <p>Transport and service vouchers appear to be a viable strategy for rapidly increasing maternal care. MakCHS can design strategies together with stakeholders using a learning-by-doing approach to take advantage of community resources.</p

Why do women not use antenatal services in low and middle income countries? A metasynthesis of qualitative studies

Background: Almost 50% of women in low & middle income countries (LMIC’s) don’t receive adequate antenatal care. Women’s views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies. Methods and Findings: Using a pre-determined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMIC’s who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line of argument synthesis. We derived policy relevant hypotheses from the findings. We included 21 papers representing the views of more than 1230 women from 15 countries. Three key themes were identified: ‘Pregnancy as socially risky and physiologically healthy’; ‘Resource use and survival in conditions of extreme poverty’and ‘Not getting it right first time’. The line of argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralized, risk-focused antenatal care programmes may be at odds with the resources, beliefs and experiences of pregnant women who underuse antenatal services. Conclusions: Our findings suggest that there may be a mis-alignment between current antenatal provision and the social and cultural context of some women in LMIC’s. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences are likely to be underused, especially when attendance generates increased personal risks of lost family resource or physical danger during travel; when the promised care is not delivered due to resource constraints; and when women experience covert or overt abuse in care settings

Malaria case-management under artemether-lumefantrine treatment policy in Uganda

<p>Abstract</p> <p>Background</p> <p>Case-management with artemether-lumefantrine (AL) is one of the key strategies to control malaria in many African countries. Yet, the reports on translation of AL implementation activities into clinical practice are scarce. Here the quality of AL case-management is reported from Uganda; approximately one year after AL replaced combination of chloroquine and sulphadoxine-pyrimethamine (CQ+SP) as recommended first line treatment for uncomplicated malaria.</p> <p>Methods</p> <p>A cross-sectional survey, using a range of quality of care assessment tools, was undertaken at all government and private-not-for-profit facilities in four Ugandan districts. Main outcome measures were AL prescribing, dispensing and counseling practices in comparison with national guidelines, and factors influencing health workers decision to 1) treat for malaria, and 2) prescribe AL.</p> <p>Results</p> <p>195 facilities, 232 health workers and 1,763 outpatient consultations were evaluated. Of 1,200 patients who needed treatment with AL according to guidelines, AL was prescribed for 60%, CQ+SP for 14%, quinine for 4%, CQ for 3%, other antimalarials for 3%, and 16% of patients had no antimalarial drug prescribed. AL was prescribed in the correct dose for 95% of patients. Only three out of seven AL counseling and dispensing tasks were performed for more than 50% of patients. Patients were more likely to be treated for malaria if they presented with main complaint of fever (OR = 5.22; 95% CI: 3.61–7.54) and if they were seen by supervised health workers (OR = 1.63; 95% CI: 1.06–2.50); however less likely if they were treated by more qualified health workers (OR = 0.61; 95% CI: 0.40–0.93) and presented with skin problem (OR = 0.29; 95% CI: 0.15–0.55). AL was more likely prescribed if the appropriate weight-specific AL pack was in stock (OR = 6.15; 95% CI: 3.43–11.05) and when CQ was absent (OR = 2.16; 95% CI: 1.09–4.28). Routine AL implementation activities were not associated with better performance.</p> <p>Conclusion</p> <p>Although the use of AL was predominant over non-recommended therapies, the quality of AL case-management at the point of care is not yet optimal. There is an urgent need for innovative quality improvement interventions, which should be rigorously tested. Adequate availability of ACTs at the point of care will, however, ultimately determine the success of any performance interventions and ACT policy transitions.</p

Improving pneumonia case-management in Benin: a randomized trial of a multi-faceted intervention to support health worker adherence to Integrated Management of Childhood Illness guidelines

<p>Abstract</p> <p>Background</p> <p>Pneumonia is a leading cause of death among children under five years of age. The Integrated Management of Childhood Illness strategy can improve the quality of care for pneumonia and other common illnesses in developing countries, but adherence to these guidelines could be improved. We evaluated an intervention in Benin to support health worker adherence to the guidelines after training, focusing on pneumonia case management.</p> <p>Methods</p> <p>We conducted a randomized trial. After a health facility survey in 1999 to assess health care quality before Integrated Management of Childhood Illness training, health workers received training plus either study supports (job aids, non-financial incentives and supervision of workers and supervisors) or "usual" supports. Follow-up surveys were conducted in 2001, 2002 and 2004. Outcomes were indicators of health care quality for Integrated Management-defined pneumonia. Further analyses included a graphical pathway analysis and multivariable logistic regression modelling to identify factors influencing case-management quality.</p> <p>Results</p> <p>We observed 301 consultations of children with non-severe pneumonia that were performed by 128 health workers in 88 public and private health facilities. Although outcomes improved in both intervention and control groups, we found no statistically significant difference between groups. However, training proceeded slowly, and low-quality care from untrained health workers diluted intervention effects. Per-protocol analyses suggested that health workers with training plus study supports performed better than those with training plus usual supports (20.4 and 19.2 percentage-point improvements for recommended treatment [p = 0.08] and "recommended or adequate" treatment [p = 0.01], respectively). Both groups tended to perform better than untrained health workers. Analyses of treatment errors revealed that incomplete assessment and difficulties processing clinical findings led to missed pneumonia diagnoses, and missed diagnoses led to inadequate treatment. Increased supervision frequency was associated with better care (odds ratio for recommended treatment = 2.1 [95% confidence interval: 1.13.9] per additional supervisory visit).</p> <p>Conclusion</p> <p>Integrated Management of Childhood Illness training was useful, but insufficient, to achieve high-quality pneumonia case management. Our study supports led to additional improvements, although large gaps in performance still remained. A simple graphical pathway analysis can identify specific, common errors that health workers make in the case-management process; this information could be used to target quality improvement activities, such as supervision (ClinicalTrials.gov number NCT00510679).</p

“Even if You Know Everything You Can Forget”: Health Worker Perceptions of Mobile Phone Text-Messaging to Improve Malaria Case-Management in Kenya

This paper presents the results of a qualitative study to investigate the perceptions and experiences of health workers involved in a a cluster-randomized controlled trial of a novel intervention to improve health worker malaria case-management in 107 government health facilities in Kenya. The intervention involved sending text-messages about paediatric outpatient malaria case-management accompanied by “motivating” quotes to health workers’ mobile phones. Ten malaria messages were developed reflecting recommendations from the Kenyan national guidelines. Two messages were delivered per day for 5 working days and the process was repeated for 26 weeks (May to October 2009). The accompanying quotes were unique to each message. The intervention was delivered to 119 health workers and there were significant improvements in correct artemether-lumefantrine (AL) management both immediately after the intervention (November 2009) and 6 months later (May 2010). In-depth interviews with 24 health workers were undertaken to investigate the possible drivers of this change. The results suggest high acceptance of all components of the intervention, with the active delivery of information in an on the job setting, the ready availability of new and stored text messages and the perception of being kept ‘up to date’ as important factors influencing practice. Applying the construct of stages of change we infer that in this intervention the SMS messages were operating primarily at the action and maintenance stages of behaviour change achieving their effect by creating an enabling environment and providing a prompt to action for the implementation of case management practices that had already been accepted as the clinical norm by the health workers. Future trials testing the effectiveness of SMS reminders in creating an enabling environment for the establishment of new norms in clinical practice as well as in providing a prompt to action for the implementation of the new case-management guidelines are justified

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

A novel nonparametric item response theory approach to measuring socioeconomic position: a comparison using household expenditure data from a Vietnam health survey, 2003

BACKGROUND: Measures of household socio-economic position (SEP) are widely used in health research. There exist a number of approaches to their measurement, with Principal Components Analysis (PCA) applied to a basket of household assets being one of the most common. PCA, however, carries a number of assumptions about the distribution of the data which may be untenable, and alternative, non-parametric, approaches may be preferred. Mokken scale analysis is a non-parametric, item response theory approach to scale development which appears never to have been applied to household asset data. A Mokken scale can be used to rank order items (measures of wealth) as well as households. Using data on household asset ownership from a national sample of 4,154 consenting households in the World Health Survey from Vietnam, 2003, we construct two measures of household SEP. Seventeen items asking about assets, and utility and infrastructure use were used. Mokken Scaling and PCA were applied to the data. A single item measure of total household expenditure is used as a point of contrast. RESULTS: An 11 item scale, out of the 17 items, was identified that conformed to the assumptions of a Mokken Scale. All the items in the scale were identified as strong items (Hi > .5). Two PCA measures of SEP were developed as a point of contrast. One PCA measure was developed using all 17 available asset items, the other used the reduced set of 11 items identified in the Mokken scale analaysis. The Mokken Scale measure of SEP and the 17 item PCA measure had a very high correlation (r = .98), and they both correlated moderately with total household expenditure: r = .59 and r = .57 respectively. In contrast the 11 item PCA measure correlated moderately with the Mokken scale (r = .68), and weakly with the total household expenditure (r = .18). CONCLUSION: The Mokken scale measure of household SEP performed at least as well as PCA, and outperformed the PCA measure developed with the 11 items used in the Mokken scale. Unlike PCA, Mokken scaling carries no assumptions about the underlying shape of the distribution of the data, and can be used simultaneous to order household SEP and items. The approach, however, has not been tested with data from other countries and remains an interesting, but under researched approach