An Evaluation of the Quality of IMCI Assessments among IMCI Trained Health Workers in South Africa

Abstract

BackgroundIntegrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa.Methodology/Principal FindingsSeventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW's had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children.Conclusion/SignificanceHealth workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.

Improving the quality of hospital care for children by supportive supervision: a cluster randomized trial, Kyrgyzstan

“…Many countries implementing the Integrated Management of Childhood Illness strategy developed by WHO and the United Nations Children’s Fund have adopted this approach. However, recent evidence indicates that training alone does not ensure better case management and, even after training, it may be difficult to incorporate new knowledge into practice 18 – 20 . Supportive supervision for staff has been proposed as an intervention for increasing adherence to clinical guidelines 20 – 22 .…”

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“…[11] The guideline should be distributed widely to all first-contact health workers, but does not obviate the need for on-going training. [12] The paper by Lochlan et al [2] describes an analysis of 47 677 blood cultures taken from children between 2008 and 2012 at the Red Cross War Memorial Children's Hospital and addresses the technique of collecting blood samples for culture and the interpretation of results. [2] Overall, 6.2% of the blood cultures revealed pathogenic organisms with fewer positive cultures in children >1 year of age [2] with contamination of blood cultures ranging from 5.9% to 7.2% per annum.…”

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“…Low HCW compliance was also observed in several other countries. One study evaluated HCW adherence to IMCI guidelines in South Africa, and found that after 32 months of training, less than 2% of health care workers refer to IMCI guidelines during pediatric visits [26]. Also, only 12% of IMCI-trained HCW's were found to check general danger signs in every child, and only 18% assessed all the main symptoms in every child.…”