Integrated Management Of Childhood Illness Guidelines Research Articles

Use integrated management of childhood illnesses guidelines: a need for adaptation for use in Ghindae hospital, Eritrea

Background: Diarrheal diseases are among the commonest causes of morbidity and mortality among infants and young children in the developing world and most commonly in the sub-Saharan including Eritrea. Integrated Management of Childhood Illnesses (IMCI) is a strategy developed by UNICEF and WHO for developing countries and other resource poor countries currently being practiced in Africa, Asia, and South America. IMCI guidelines are simplified system of diagnosis and treatment that is designed for use by health workers with limited training and little or no laboratory support. According to this guideline bloody diarrhea is treated with ORS, additional fluid support and cotrimoxazole empirically with the assumption that the etiologic agent is shigella. If the child does not improve on follow up then metronidazole is added with the assumption that the etiologic agent is parasitic mainly amoeba and giardia. Objective: The objective of this study was to assess the use of IMCI guidelines in children presenting with diarrhea at Ghindae Hospital. Methods: The study was a prospective in which all children below the age of 5 years, who presented primarily with all forms of diarrhea during the one month period from June 1st 2008 to June 30 2008, were included in the study. All stool samples were subjected to laboratory analysis. Results: Eighty seven children who presented with all forms of diarrhea to the IMCI OPD or as IPD were included in the study. More than 50% of the cases had parasitic infestation mainly Amoeba and Giardia. Less than 5% of the children presented with mild or severe dehydration. The majority (92%) of the cases had no dehydration had diarrhea with no dehydration. Conclusion: In Ghindae community there is a justification for use of metronidazole as a first line treatment of bloody diarrhea, because of the preponderance of parasitic infestation instead of bacterial causes for the majority of cases of children presenting with diarrhea, a clear need for adaptation of IMCI

Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV

BackgroundIntegrated Management of Childhood Illness (IMCI) is a WHO/UNICEF strategy to improve child survival in resource poor settings. South Africa adopted IMCI in 1997, and IMCI guidelines were adapted to include identification and management of HIV infected and exposed children. This study describes the validity of the IMCI/HIV algorithm when used by IMCI experts, the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice, and the burden of HIV among children under 5 years attending first level health facilities.MethodsSeventy seven randomly selected IMCI trained health workers were observed in 74 health facilities in two provinces of South Africa. Consultations were observed with 1357 sick children; each child was reassessed by an IMCI expert to confirm the correct findings. Consent was requested for HIV testing of all children who attended with a parent or legal guardian. Positive rapid HIV tests were confirmed with HIV PCR in children aged less than 18 months. HIV positive children had a CD4 count and HIV clinical staging done.ResultsOf 1064 children with HIV results available, 76 (7.1% CI: 5.7% - 8.9%) children were confirmed HIV positive. IMCI experts using the HIV algorithm classified 54/76 (71.1% CI: 59.5%-80.9%) HIV positive children as suspected symptomatic HIV, and 15/22 remaining HIV positive children were identified as HIV exposed. Therefore, 69/76 (90.8% CI: 81.9-96.2) HIV infected children were identified by IMCI experts. No classification was made for HIV by observed health workers in 899/1357(66.2%) children.906/1243(72.9%) mothers had been tested previously for HIV, of whom 221(24.4%) reported testing positive. Of 221 children therefore identified as HIV exposed, only 78(35.3%) had been tested for HIV within routine services.ConclusionThe HIV algorithm is a valid tool for identifying HIV infected and exposed children when correctly and comprehensively implemented. However, it is not being used by IMCI trained health workers in routine practise, leading to a failure to implement life saving interventions.

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

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.

Ability of mothers to assess the presence of fever in their children: Implication for the treatment of fever under the IMCI guidelines

Fever is a common reason for seeking medical attention, with febrile illnesses accounting for 10% to 20% of pediatric visits to emergency departments. A history of fever or presence of fever by palpation or measured temperature is required on the Integrated Management of Childhood Illnesses (IMCI) algorithms as a reason for the assessment of fever, which will lead to specific classifications that are linked to treatment protocols. Therefore, the WHO and its partners assume that mothers are able to assess their children for the presence of fever. To evaluate the ability of mothers to determine the presence of fever in their children by tactile examination of their children. We prospectively studied 126 mother-child pairs attending the pediatric outpatient clinic of Ahmadu Bello University Teaching Hospital (ABUTH). Mothers of children 2 months to 5 years of age who mentioned fever as part of the presenting complaints were studied using a structured questionnaire regarding their children's illness, temperature status and their educational level. A total of 126 mother-child pairs were studied, of which 44 (34.9%) of the mothers had had their education extended to secondary school level and only 15 (11.9%) had their education extended to a tertiary level. Fever was present in 82 (65.1%) of the children when their temperatures were determined by thermometer. The mothers correctly identified 79 (sensitivity of 96.3%) of the children who were truly febrile and 19 (specificity of 43.2%) of those who were truly nonfebrile. The predictive value of a positive test was 76.0%, and the predictive value of a negative test was 86.4%. The results showed that mothers in our environment, as has been observed in other parts of the world, are able to correctly assess the presence or absence of fever in their children.

How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study

Countries with high rates of child mortality tend to have shortages of qualified health workers. Little rigorous evidence has been done to assess how much the quality of care varies between types of health workers. We compared the performance of different categories of health workers who are trained in Integrated Management of Childhood Illness (IMCI). We analysed data obtained from first-level health facility surveys in Bangladesh (2003), Brazil (2000), Uganda (2002), and Tanzania (2000). We compared the clinical performance of health workers with longer duration of preservice training (those with >4 years of post-secondary education in Brazil or >3 years in the other three countries) and shorter duration (all other health workers providing clinical care). We calculated quality of care with indicators of assessment, classification, and management of sick children according to IMCI guidelines. Every child was examined twice, by the IMCI-trained health worker being assessed and by a gold-standard supervisor. 272 children were included in Bangladesh, 147 in Brazil, 231 in Tanzania, and 612 in Uganda. The proportions of children correctly managed by health workers with longer duration of preservice training in Brazil were 57.8% (n=43) versus 83.7% (n=61) for those with shorter duration of training (p=0.008), and 23.1% (n=47) versus 32.6% (n=134) (p=0.03) in Uganda. In Tanzania, those with longer duration of training did better than did those with shorter duration in integrated assessment of sick children (mean index of integrated assessment 0.94 [SD 0.15] vs 0.88 [0.13]; p=0.004). In Bangladesh, both categories of health worker did much the same in all clinical tasks. We recorded no significant difference in clinical performance in all the other clinical tasks in the four countries. IMCI training is associated with much the same quality of child care across different health worker categories, irrespective of the duration and level of preservice training. Strategies for scaling up IMCI and other child-survival interventions might rely on health workers with shorter duration of preservice training being deployed in underserved areas.

Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study

Guidelines on integrated management of childhood illness (IMCI) for severe pneumonia recommend referral to hospitals. However, in many settings, children who are referred do not actually attend hospital, which severely limits appropriate care. We aimed to assess the safety and effectiveness of modified guidelines that allowed most children with severe pneumonia to be treated locally in first-level facilities, with referral only for those with danger signs or other severe classifications. We did an observational cohort study in ten first-level health facilities in Matlab, rural Bangladesh that had implemented IMCI guidelines. We assessed children with severe pneumonia who were aged between 2 and 59 months, and for whom we could obtain complete information, in two cohorts: 261 children who presented to these facilities between May, 2003, and April, 2004 (before implementation of the modified guidelines) and 1271 children between September, 2004, and August, 2005 (after full implementation). We obtained information about the characteristics and management of their illness, including referrals and admissions to hospital, from facility records. Staff visited households to obtain details of treatment, socioeconomic information, and final outcome, including mortality data. 245 (94%) of 261 children who had severe pneumonia were referred to hospital before the guidelines were modified, compared with 107 (8%) of 1271 after implementation (p<0.0001). 94 (36%) children with severe pneumonia received correct management before the guidelines were modified, compared with 1145 (90%) children after implementation (p<0.0001). Before modification of the guidelines, three children with severe pneumonia who presented at first-level facilities died, with a case-fatality rate of 1.1%; after modification, seven children died, with a case-fatality rate of 0.6% (p=0.39). Local adaptation of the IMCI guidelines, with appropriate training and supervision, could allow safe and effective management of severe pneumonia, especially if compliance with referral is difficult because of geographic, financial, or cultural barriers.

Low birth weight and incidence of first malaria episode and adherence to malaria treatment protocols in infants in Chikwawa district, Malawi.

In Malawi, malaria is a leading cause of infant morbidity and mortality. Low birthweight and fetal anaemia are also a common occurrence. The relationship between birthweight and fetal anaemia and malaria morbidity in infancy is not known. To investigate the relationship between incidence of first malaria episode and birthweight and fetal anaemia and to investigate adherence of health workers to Integrated Management of Childhood Illnesses (IMCI) malaria treatment protocol. A stratified sample of 561 infants was selected based on low birth weight (LBW, <2.5Kgs), fetal anaemia (FA, Hbcord <12g/dl) and matched controls with normal birth weight (NBW) and no fetal anaemia (NFA). Cases were defined as LBW FA, LBW NFA, and NBW FA. Cumulative incidence to first malaria episode did not significantly differ between the study groups and the controls. Sulphadoxine-pyrimethamine (SP) was prescribed to the majority of malaria cases (89.3%). There is no relationship between birthweight and fetal anaemia and first malaria episode. There is good adherence to IMCI guidelines for malaria treatment.

Integrating HIV management for children into the Integrated Management of Childhood Illness guidelines

The WHO/UNICEF strategy of Integrated Management of Childhood Illness (IMCI) has been adopted as a strategy for improving paediatric care in resource-poor settings. The original IMCI guidelines recommend referral of children with severe or recurrent illnesses such as those common in HIV/AIDS, however the specific identification and management was not included. In many countries, especially in sub-Saharan Africa, HIV/AIDS contributes significantly to child morbidity and mortality. There was a need to include the specific assessment and management of symptomatic HIV infection in IMCI guidelines. A draft HIV component of the IMCI guidelines was developed, which included management of symptomatic HIV cases with referral for counselling and testing, and was evaluated in South Africa. A revised version was then validated in Ethiopia and Uganda where HIV, malnutrition and malaria prevalence is different from South Africa. IMCI materials have been adapted to include an HIV component. Currently, very few children under 15 years of age receive antiretroviral therapy (ART). Chronic HIV care of children, including ART for children, has been developed within the Integrated Management of Adolescent and Adult Illness (IMAI) initiative of the WHO. Through this initiative, the WHO is assisting countries to facilitate care and treatment of children undergoing ART.

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

To assess the practice of skills learnt by basic health workers for 4 - 8 weeks and one year after IMCI training, and to identify the gaps in practices due to various constraints. The Anganwadi 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 1st batch of AWWs 1 year after training in IMCI and a second visit was given 4-8 weeks after the 1st visit. The 2nd batch of AWWs was followed up 4-8 weeks after training in IMCI. The performance on correct treatment of cases by AWWs weeks were trained 4-6 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 1st follow up to 52.1% during 2nd follow up visit. The average number of cases seen by AWWs increased from 6.6 in 1st follow up to 9.3 during second follow up of the same AWWs. 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.

The Validity of Diagnostic Criteria for Streptococcal Pharyngitis in Integrated Management of Childhood Illness (IMCI) Guidelines

The WHO's Integrated Management of Childhood Illness (IMCI) programme is being implemented in Turkey with an additional section relating to throat problems for our country's adaptation. The aim of this study is to evaluate the validity of this additional part and suggest new combinations for the diagnosis of streptococcal pharyngitis to improve the guidelines. Throat swabs were obtained from 245 children between 0 and 17 years of age with signs and symptoms of upper respiratory tract infections. Considering the throat culture based diagnosis as the gold standard, the validity of the symptoms alone and in combinations were calculated. The combination in Turkey's IMCI guideline was found to be 36.9 per cent sensitive and 68.3 per cent specific. Sensitivities of combinations including at least two of the following three symptoms, namely sore throat, pharyngeal erythema, and pharyngeal exudates or sore throat, pharyngeal erythema, and fever, were 76.9 and 87.7 per cent, respectively. Specificities of the same combinations were 49.4 and 30.6 per cent. We concluded that new combinations with a higher sensitivity may be considered as a criterion for antibiotic treatment.

Drug treatment costs: projected impact of using the integrated management of childhood illnesses.

The strategy of integrated management of childhood illness (IMCI) aims at improving the skills of first level health workers and consequently, improving the survival chances of children. The guidelines have been shown to be cost-effective. We aimed to determine the potential impact of using IMCI guidelines on drug treatment cost. The cost of drugs prescribed for 129 sick children, by first level health workers, who were managed at three primary health facilities in Sabon Gari Local Government Area of Kaduna State, was calculated. The corresponding cost using the IMCI guidelines was also calculated. There were 74 males and 55 females (M:F=1.3:1). An average of 4.5 drugs per patient were prescribed by the health workers compared to 2.3 drugs per patient when using the IMCI guidelines. The total cost of drugs prescribed by the health workers was N15,279.39 with an average of N118.44 per child. The corresponding costs had the IMCI guidelines been used were N3,062.53 and N23.73, respectively. Treatment cost using the traditional method was 4.98 times more expensive than using methods advocated by the IMCI guidelines. The projected cost savings related to drugs when using IMCI guidelines were based on the assumption that inappropriate drugs would not be prescribed by health workers once they are introduced to and started using the IMCI guidelines.

Inequities among the very poor: health care for children in rural southern Tanzania

Few studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania. In a baseline household survey in Tanzania early in the implementation phase of integrated management of childhood illness (IMCI), we included cluster samples of 2006 children younger than 5 years in four rural districts. Questions focused on the extent to which carers' knowledge of illness, care-seeking outside the home, and care in health facilities were consistent with IMCI guidelines and messages. We used principal components analysis to develop a relative index of household socioeconomic status, with weighted scores of information on income sources, education of the household head, and household assets. 1026 (52%) of 1968 children reported having been ill in the 2 weeks before the survey. Carers of 415 (41%) of 1014 of these children had sought care first from an appropriate provider. 71 (26%) carers from families in the wealthiest quintile knew > or =2 danger signs compared with 48 (20%) of those from the poorest (p=0.03 for linear trend across quintiles) and wealthier families were more likely to bring their sick children to a health facility (p=0.02). Their children were more likely than poorer children to have received antimalarials, and antibiotics for pneumonia (p=0.0001 and 0.0048, respectively). Care-seeking behaviour is worse in poorer than in relatively rich families, even within a rural society that might easily be assumed to be uniformly poor.

Evaluation of the Integrated Management of Childhood Illness guidelines for treatment of intestinal helminth infections among sick children aged 2–4 years in western Kenya

Anthelmintic treatment of sick preschool-age children at health facilities is a potentially effective strategy for intestinal helminth control in this age-group. We conducted a study from July 1998 to February 1999 in western Kenya to determine whether the Integrated Management of Childhood Illness (IMCI) guidelines' clinical assessment can be used to identify helminth-infected children, and to evaluate the nutritional benefit of treating sick children without pallor with an anthelmintic (mebendazole is already part of IMCI treatment for sick children aged 2–4 years with palmar pallor in areas where hookworm and Trichuris trichiura infections are endemic). Sick children aged 2–4 years seen at 3 rural health facilities were clinically evaluated and tested for haemoglobin concentration, malaria parasites, and intestinal helminths. Children without pallor were randomly assigned to receive a single dose of 500 mg of mebendazole or a placebo and re-examined 6 months later. Among the 574 children enrolled, 11% had one or more intestinal helminths. Most infections were of light intensity. Selected clinical signs and symptoms available from the IMCI assessment, including palmar pallor and low weight-for-age, were not associated with helminth infection. Six months after enrolment, no differences in growth of children without pallor were observed between the mebendazole ( n = 166) and placebo ( n = 181) groups. However, there was a significantly greater mean increase in weight, height, and weight-for-age Z score among the helminth-infected children in the mebendazole group ( n = 22) as compared with helminth-infected children in the placebo group ( n = 20). We conclude that even lightly infected preschool-age children without palmar pallor benefit from anthelmintic treatment; however, in this study setting of low helminth prevalence and intensity, helminth-infected children could not be identified using the IMCI guidelines. Cost-effectiveness studies are needed to help define helminth prevalence thresholds for routine anthelmintic treatment of sick preschool-age children seen at first-level health facilities.

Research to support household and community IMCI. Report of a meeting, 22-24 January 2001, Baltimore, Maryland, USA.

The Integrated Management of Childhood Illness (IMCI) strategy combines improved case management of childhood illness with aspects of nutrition, immunization, disease prevention, and promotion of growth and development. The household and community component of IMCI was formulated to reach the numerous sick children who are ill and often die at home without ever being treated by a trained healthcare practitioner. In January 2001, USAID (Child Health Research Project and BASICS II) and the CORE Group sponsored a meeting in Baltimore, Maryland, to determine the research needed to implement household and community IMCI effectively. This paper summarizes the presentations at that meeting and highlights the research and programme priorities expressed using the three-element approach devised by the CORE Group and USAID (BASICS II and Child Survival Technical Support Project). Research priorities to improve partnerships between health facilities and the communities they serve (Element 1) include finding ways to increase community involvement and management of health facilities, establishing accurate costs for community IMCI services, and formulating cost-recovery mechanisms tailored to local circumstances. Programme priorities in Element 1 include establishment of systems for maintenance of an adequate supply of essential equipment and medicines, while retaining access for the poor and ensuring adequate referral mechanisms for severely-ill patients that include monitoring and incentives for the performance of health workers. Research priorities to increase appropriate, accessible care and information from community-based care providers (Element 2) consist of activities to design simplified IMCI guidelines for use by community health workers (CHWs) and volunteers and evaluation of the impact of using these guidelines on morbidity and mortality. Also a priority item in this category is experimenting with ways to teach mothers and families to care for sick children at home and strategies to improve the practice of medicine in the private sector. More research is also needed to improve the quality of nutritional and preventive health counselling given by CHWs and to find ways to make community IMCI interventions sustainable. Programme priorities in Element 2 include efforts at the national level to establish policies to improve care by traditional and private care providers and to define the position of volunteer workers in the national health system. Research priorities to integrate promotion of key family practices critical for public health (Element 3) are focused on determining which interventions are the most effective in reducing child morbidity and mortality at the household and community levels, finding the best methods of delivering these interventions, and implementing these and scaling up in essential service packages. Particular issues in child health, needing urgent attention from the research and programme communities, are HIV/AIDS and neonatal morbidity and mortality.

Palmar Pallor as an Indicator for Anthelminthic Treatment Among Ill Children Aged 2-4 Years—Western Kenya, 1998

Infections with the soil-transmitted intestinal helminths (i.e., Ascaris lumbricoides, Trichuris trichiura, and hookworm), estimated to affect approximately 1 billion persons, are among the most common and widespread human infections. Among children aged <5 years, intestinal helminth infections cause malnutrition and anemia, two important causes of mortality. Anthelminthic treatment (deworming) improves nutritional status of school-aged children. The World Health Organization and the United Nations Children's Fund (UNICEF) have developed guidelines that include interventions for anemia and malnutrition in the integrated management of childhood illness (IMCI) for children aged <5 years seen at first-level health-care facilities in developing countries. Under the IMCI guidelines, in geographic areas where hookworm or Trichuris infections are endemic, children aged 2-4 years with palmar pallor are treated with an anthelminthic drug. This report summarizes an investigation of the use of palmar pallor as an indication for anthelminthic treatment among ill children aged 2-4 years seen at first-level health-care facilities in rural western Kenya; the investigation found that palmar pallor was associated with anemia but not with intestinal helminth infection.

Integrated approach to child health in developing countries

This article focuses on the integrated approach to child health in developing countries. The Integrated Management of Childhood Illness (IMCI) is a strategy developed by ten programs of WHO working with UN International Childrens Emergency Fund and many other agencies institutions and individuals. IMCI focuses on the disease of childhood that causes the greatest global burden while allowing for the content to be adapted to an individual countrys needs. An integrated approach is justified by good clinical practice and most importantly treating the child as a whole and not simply his or her most obvious disease. The strategy involves not only curative care but also interventions to promote healthy growth and development and prevent diseases. In health facilities the IMCI strategy promotes the accurate identification of childhood illnesses in outpatient settings ensures appropriate combined treatment of all major illnesses strengthens the counseling of caretakers and the provision of preventive services and speed up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. In the home setting it promotes appropriate early home care and care seeking improved nutrition and prevention and the correct implementation of prescribed care. Through improving the coordination and quality of services provided by existing child health and other programs the IMCI strategy will help increase the effectiveness of care and in time reduce recurrent costs.

Integrated management of childhood illness

Each year, at least 4 million African children die before they reach their fifth birthday, and 70% of the deaths are caused by pneumonia, diarrhea, malaria, measles, malnutrition, or, more commonly, a combination of these. Despite the fact that sick children often have more than one condition, busy clinics tend to treat only the one that is most obvious. With much of the effort of the past two decades directed to diarrhea, health workers have been taught their clinical skills in a piecemeal, rather than an integrated, fashion. In response to this problem, the World Health Organization and the UN Children's Fund developed a training course for the integrated management of childhood illnesses (IMCI) in 1993. IMCI is now being used in Uganda, Tanzania, and Zambia, and other African countries are preparing to institute it. IMCI relies on a straightforward clinical assessment and classification of illness that does not require the use of a laboratory. IMCI identifies general danger signs that may call for hospitalization of the child and then bases its assessment on the presence of 1) cough and difficulty breathing, 2) diarrhea, 3) fever, 4) measles, 5) ear infection, and 6) malnutrition. All sick children are screened for all of these conditions because IMCI capitalizes on the presence of the child in the clinic (vaccinations are also given if necessary). Training for IMCI involves 11 days, half of which are spent in clinical practice and demonstration and half in the classroom. Each country must adapt the IMCI guidelines and training course to meet its specific needs. Such adaptation provides an opportunity for collaboration among disease-specific programs; it stimulates a review of technical and clinical guidelines; and it provides an opportunity for the health system to focus on its essential drug needs, referral care, and supervisory system.