Management Of Childhood Illness Guidelines Research Articles

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia.

Pulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia. This was a retrospective pooled analysis of two outpatient datasets of 3-35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2 < 93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO. 12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2 < 93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2 < 93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2 < 93% cases. Both LASSO models had similar performance for a SpO2 < 90%. In the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.

The added value of using of pulse oximeter into the integrated management of childhood illness guidelines to better identify and manage severe cases among children under-5 years old in west africa, june 2021 to june 2022

The added value of using of pulse oximeter into the integrated management of childhood illness guidelines to better identify and manage severe cases among children under-5 years old in west africa, june 2021 to june 2022

Pneumococcal concentration and serotype distribution in preschool children with radiologically confirmed pneumonia compared to healthy controls prior to introduction of pneumococcal vaccination in Zanzibar: an observational study

The World Health Organization recommends pneumococcal vaccination (PCV) in the first year of life. We investigated pneumococcal serotypes in children with clinical or radiologically confirmed pneumonia and healthy controls prior to PCV13 vaccine introduction in Zanzibar. Children (n = 677) with non-severe acute febrile illness aged 2-59months presenting to a health centre in Zanzibar, Tanzania April-July 2011 were included. Nasopharyngeal swabs collected at enrolment were analysed by real-time PCR to detect and quantify pneumococcal serotypes in patients (n = 648) and in healthy asymptomatic community controls (n = 161). Children with clinical signs of pneumonia according to the Integrated Management of Childhood illness guidelines ("IMCI pneumonia") were subjected to a chest-X-ray. Consolidation on chest X-ray was considered "radiological pneumonia". Pneumococcal DNA was detected in the nasopharynx of 562/809 (69%) children (70% in patients and 64% in healthy controls), with no significant difference in proportions between patients with or without presence of fever, malnutrition, IMCI pneumonia or radiological pneumonia. The mean pneumococcal concentration was similar in children with and without radiological pneumonia (Ct value 26.3 versus 27.0, respectively, p = 0.3115). At least one serotype could be determined in 423 (75%) participants positive for pneumococci of which 33% had multiple serotypes detected. A total of 23 different serotypes were identified. One serotype (19F) was more common in children with fever (86/648, 13%) than in healthy controls (12/161, 7%), (p = 0.043). Logistic regression adjusting for age and gender showed that serotype 9A/V [aOR = 10.9 (CI 2.0-60.0, p = 0.006)] and 14 [aOR = 3.9 (CI 1.4-11.0, p = 0.012)] were associated with radiological pneumonia. The serotypes included in the PCV13 vaccine were found in 376 (89%) of the 423 serotype positive participants. The PCV13 vaccine introduced in 2012 targets a great majority of the identified serotypes. Infections with multiple serotypes are common. PCR-determined concentrations of pneumococci in nasopharynx were not associated with radiologically confirmed pneumonia. Trial registrationClinicaltrials.gov (NCT01094431).

Evaluation of Adherence of Health-Care Workers to Integrated Management of Childhood Illness Guidelines in the Context of the Free Care Program in Burkina Faso.

To reduce child mortality in children younger than 5 years, Burkina Faso has been offering free care to this population of children since 2016. The free care program is aligned with the Integrated Management of Childhood Illness (IMCI) guidelines. Given that the number of studies that evaluated the competence of health-care workers (HCWs) during the free care program was limited, we assessed the adherence level of HCWs to the IMCI guidelines in the context of free care. This was a secondary data analysis. Data were obtained from a cross-sectional study conducted from July to September 2020 in 40 primary health-care centers and two district hospitals in the Hauts-Bassins region in Burkina Faso. Our analysis included 419 children younger than 5 years old who were consulted according to IMCI guidelines. Data were collected through direct observation using a checklist. The overall score of adherence of HCWs to IMCI guidelines was 57.8% (95% CI, 42.6-73.0). The mean adherence score of the evaluation of danger signs was 71.9% (95% CI, 58.7-85.1). The mean adherence score of following IMCI guidelines was significantly greater in boys (54.2%) compared with girls (44.6%; P < 0.001). Adherence scores of the performance of different IMCI tasks were significantly different across HCW categories. The overall adherence of HCWs to IMCI guidelines in the context of free care was greater than the adherence reported before the implementation of free care in Burkina Faso. However, this assessment needs to be performed nationwide to capture the overall adherence of HCWs to IMCI guidelines in the context of the free care program.

Adherence and Implementation-related Challenges of Integrated Management of Childhood Illness Guidelines among Nurses at Health Centers in Port Harcourt, Nigeria

Adherence and Implementation-related Challenges of Integrated Management of Childhood Illness Guidelines among Nurses at Health Centers in Port Harcourt, Nigeria

Young infant clinical signs study--, Pakistan: a data note.

Neonatal sepsis is the leading cause of child death globally with most of these deaths occurring in the first week of life. It is of utmost public health importance that clinical signs predictive of severe illness and need for referral are identified early in the course of illness. From 2002-2005, a multi country trial called the Young Infant Clinical Signs Study (YICSS) was conducted in seven sites across three South-Asian (Bangladesh, India, and Pakistan), two African (Ghana, and South Africa), and one South American (Bolivia) country. The study aimed to develop a simplified algorithm to be used by primary healthcare workers for the identification of sick young infants needing prompt referral and treatment. The main study enrolled 8,889 young infants between the ages of 0-59 days old. This dataset contains observations on 2950 young infants aged 0-59 days from the Pakistan site. The data was collected between 2003-2004 with information on the most prevalent signs and symptoms. The data from this study was used to update the Integrated Management of Childhood Illness guidelines. The World Health Organisation (WHO) seven-sign algorithm has been used in other major community-based trials to study possible serious bacterial infection and its treatment regimens.

Clinical Outcomes of Pneumonia and Other Comorbidities in Children Aged 2-59 Months in Lilongwe, Malawi: Protocol for the Prospective Observational Study "Innovative Treatments in Pneumonia".

BackgroundPneumonia is the leading infectious cause of death worldwide among children below 5 years of age. Clinical trials are conducted to determine optimal treatment; however, these trials often exclude children with comorbidities and severe illness.ConclusionsGiven the paucity of data from Africa, African-based research is necessary to establish optimal management of childhood pneumonia in malaria-endemic settings in the region. An expanded evidence base that includes children with pneumonia and other comorbidities, who are at high risk for mortality or have other complications and are therefore typically excluded from childhood pneumonia clinical trials, can contribute to future iterations of the World Health Organization Integrated Management of Childhood Illness guidelines.MethodsThe study enrolled 1000 children with pneumonia presenting to the outpatient departments of Kamuzu Central or Bwaila District Hospitals in Lilongwe, Malawi, who were excluded from concurrent randomized controlled clinical trials investigating fast breathing and chest indrawing pneumonia and who met the inclusion criteria for this prospective observational study. Each child received standard care for their illnesses per Malawian guidelines and hospital protocol and was prospectively followed up with scheduled study visits on days 1, 2 (if hospitalized), 6, 14 (in person), and 30 (by phone). Our primary objectives are to describe the clinical outcomes of children who meet the inclusion criteria for this study and to investigate whether the percentages of children cured at day 14 among those with either fast breathing or chest indrawing pneumonia and comorbidities such as severe malaria, anemia, severe acute malnutrition, or HIV are lower than those in children without these comorbidities in the standard care groups in concurrent clinical trials. This study was approved by the Western Institutional Review Board, Malawi College of Medicine Research and Ethics Committee, and the Malawi Pharmacy, Medicines and Poisons Board.ObjectiveThis prospective observational study aimed to assess the clinical outcomes of children aged 2-59 months with both pneumonia and other comorbidities in a malaria-endemic region of Malawi.ResultsThe Innovative Treatments in Pneumonia project was funded by the Bill and Melinda Gates Foundation (OPP1105080) in April 2014. Enrollment in this study began in 2016, and the primary results are expected in 2019.International Registered Report Identifier (IRRID)DERR1-10.2196/13377

Comparative Study Between Integrated Management of Childhood Illness Guidelines and Traditional Methods in Management of Acute Pharyngitis among Children Under Five Years in Zagazig District, Egypt

Background: Pharyngitis is one of the most frequently faced pediatric problems with serious complications in primary care. Objective(s): To compare between Integrated Management of Childhood Illness (IMCI) guidelines and traditional management concerning diagnosis and antibiotic prescription for acute pharyngitis in children less than 5 years, as well as to determine validity of IMCI guidelines in diagnosis of acute pharyngitis by comparing their results to throat culture as a golden standard. Methods: A comparative cross-sectional study was conducted in one primary health care center and one unit where IMCI guidelines were implemented; as well as one center and one unit where traditional management of acute pharyngitis was implemented in Zagazig district, on 343 children under five years complaining of sore throat or difficult feeding. About 86 children were randomly selected from each health facility during the period of first of January until end of June 2017. Doctor’s clinical diagnosis and antibiotic prescription were reported for all children, while throat swabs were taken from children managed according to IMCI guidelines for bacterial culture. Results: According to IMCI, only 11 % of children were diagnosed as bacterial pharyngitis, antibiotic prescription was significantly lower among those managed according to IMCI compared to traditional methods (11% & 96.5% respectively, P<0.001). However, throat culture revealed that 28.5% of children managed according to IMCI guidelines had positive bacterial growth. Sensitivity of IMCI guidelines to detect bacterial cases of pharyngitis was only 36.7 % and Positive Predictive Value (PPV) was 94.7%, while their specificity to exclude bacterial and detect viral infection was about 99.2% and the Negative Predictive Value (NPV) was 79.7%. Conclusion: Application of IMCI guidelines is considered valuable in prevention of antibiotic abuse. However, the sensitivity of IMCI guidelines to detect bacterial pharyngitis was 36.7%. Key words: integrated management of childhood illness guidelines, validity, acute pharyngitis

Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys

BackgroundIntegrated Management of Childhood Illness (IMCI) is regarded as a standard public health approach to lowering child mortality in developing countries. However, little is known about how health workers adhere to the guidelines at the national level in sub-Saharan African countries.MethodsData from the Service Provision Assessment surveys of Namibia (NA) (survey year: 2009), Kenya (KE) (2010), Tanzania (TZ) (2006) and Uganda (UG) (2007) were analysed for adherence to the IMCI guidelines by health workers. Potential influencing factors included the survey country, patient’s age, the different levels of the national health system, the training level of the health care provider (physician, non-physician clinician, nurse-midwife, auxiliary staff), and the status of re-training in IMCI.ResultsIn total, 6856 children (NA: 1495; KE: 1890; TZ: 2469; UG: 1002 / male 51.2–53.5%) aged 2–73 months (2–24 months, 65.3%; median NA: 19 months; KE: 18 months; TZ: 16 months; UG: 15 months) were clinically assessed by 2006 health workers during the surveys.Less than 33% of the workers carried out assessment of all three IMCI danger signs, namely inability to eat/drink, vomiting everything, and febrile convulsions (NA: 11%; KE: 11%; TZ: 14%; UG: 31%) while the rate for assessing all three of the IMCI main symptoms of cough/difficult breathing, diarrhoea, and fever was < 60% (NA: 48%; KE: 34%; TZ: 50%; UG: 57%). Physical examination rates for fever (temperature) (NA: 97%; KE: 87%; TZ: 73%; UG: 90%), pneumonia (respiration rate/auscultation) (NA: 43%; KE: 24%; TZ: 25%; UG: 20%) and diarrhoea (dehydration status) (NA: 29%; KE: 19%; TZ: 20%; UG: 39%) varied widely and were highest when assessing children with the actual diagnosis of pneumonia and diarrhoea.Adherence rates tended to be higher in children ≤ 24 months, at hospitals, among higher-qualified staff (physician/non-physician clinician) and among those with recent IMCI re-training.ConclusionDespite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries. IMCI training should continue to be provided to all health staff, particularly nurses, midwives, and auxiliary staff, with periodic re-training and an emphasis to equally target children of all age groups.

Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions.

This Viewpoints article details our recommendation for the World Health Organization Integrated Management of Childhood Illness guidelines to consider additional referral or daily monitoring criteria for children with chest indrawing pneumonia in low-resource settings. We review chest indrawing physiology in children and relate this to the risk of adverse pneumonia outcomes. We believe there is sufficient evidence to support referring or daily monitoring of children with chest indrawing pneumonia and signs of severe respiratory distress, oxygen saturation <93% (when not at high altitude), moderate malnutrition, or an unknown human immunodeficiency virus (HIV) status in an HIV-endemic setting. Pulse oximetry screening should be routine and performed at the earliest point in the patient care pathway as possible. If outpatient clinics lack capacity to conduct pulse oximetry, nutritional assessment, or HIV testing, then we recommend considering referral to complete the evaluation. When referral is not possible, careful daily monitoring should be performed.

Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety: a cross-sectional survey in the private sector in Uganda

ObjectivesThe main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to...

Primary Health Care Physicians' Adherence and Attitude Towards Integrated Management of Childhood Illness Guidelines in Alexandria Governorate in Egypt.

Background:Integrated Management of Childhood Illness (IMCI) is a cost-effective strategy that improves the quality of care provided to under-five children. Alexandria was the first governorate that applied the Integrated Management of Childhood Illness guidelines in Egypt. The aim of this study was to assess the degree of primary health care physicians’ adherence and attitude towards those guidelines after 17 years of application.Methods:This cross-sectional study was carried out on a representative sample from the primary health care facilities in Alexandria from which physicians using IMCI guidelines were included in the study. The sample units were chosen randomly from all districts of Alexandria. Observational checklists were developed to assess the degree of adherence of physicians based on the guidelines booklet.Results:The highest adherence score reported was that of writing disease classification (100%). As regards infants aged up to 2 months, the highest physicians’ adherence score reported was that of jaundice and possible bacterial infection assessment (100% and 95% respectively). And in spite of its importance, only 85.7% of physicians were complied with weight assessment and its plotting in the growth curve. For children aged from 2 months up to 5 years physicians were generally well complied with the guidelines especially for assessment of dangerous signs and possible bacterial infection.Conclusion:Despite being applied for years, IMCI guidelines still show certain areas of poor adherence, an issue that need further investigation in order to maximize physicians’ adherence and achieve the best of their performance.

What factors are associated with compliance of integrated management of childhood illness guidelines in Egypt? An analysis using the 2004 egypt service provision assessment survey

What factors are associated with compliance of integrated management of childhood illness guidelines in Egypt? An analysis using the 2004 egypt service provision assessment survey

Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review

Implementation of the Integrated Management of Childhood Illness (IMCI) strategy with an 11-day training course for health workers improves care for ill children in outpatient settings in developing countries. The 11-day course duration is recommended by the World Health Organization, which developed IMCI. Our aim was to determine if shortening the training (to reduce cost) reduces its effectiveness. We conducted a systematic review to compare IMCI's effectiveness with standard training (duration ≥ 11 days) versus shortened training (5-10 days). Studies were identified from a search of MEDLINE, two existing systematic reviews, and by contacting investigators. We included published or unpublished studies that evaluated IMCI's effectiveness in developing countries and reported quantitative measures of health worker practices related to managing ill children under 5 years old in public or private health facilities. Summary measures were the median of effect sizes for all outcomes from a given study, and the percentage of patients needing oral antimicrobials or rehydration who were treated according to IMCI guidelines. Twenty-nine studies were included. Direct comparisons from three studies showed little difference between standard and shortened training. Indirect comparisons from 26 studies revealed that effect sizes for standard training versus no IMCI were greater than shortened training versus no IMCI. Across all comparisons, differences ranged from -3 to +23 percentage-points, and our best estimate was a 2 to 16 percentage-point advantage for standard training. No result was statistically significant. After IMCI training (of any duration), 34% of ill children needing oral antimicrobials or rehydration were not receiving these treatments according to IMCI guidelines. Based on limited evidence, standard IMCI training seemed more effective than shortened training, although the difference might be small. As sizable performance gaps often existed after IMCI training, countries should consider implementing other interventions to support health workers after training, regardless of training duration.

Effect of adopting integrated management of childhood illness guidelines on drug use at a primary health care center: a case study from Egypt.

Background:Integrated Management of Childhood Illness (IMCI) is a cost- effective strategy that improves the quality of care through the use of evidence- based management protocols for the most common causes of childhood death and illness. Evidence- based clinical guidelines are critical to promoting rational use of medicines. Despite the large number of studies that assessed process and outcome of care delivered to children utilizing IMCI protocol, there is a scarcity of studies that assessed the effect of adopting IMCI on the drug use.Aims:To examine the impact of adopting IMCI guidelines on drug use at one of the primary health care (PHC) centers, Alexandria, Egypt.Settings and Design:Retrospective cohort study, conducted in clinic “A” not adopting IMCI guidelines and clinic “B” adopting IMCI guidelines at one of the PHC centers in Alexandria, Egypt for the period from January-- end of June 2010.Materials and Methods:A data collection sheet was designed to collect the required variables (based on WHO/ INRUD selected drug use indicators) from the medical records of children under five years.Statistical Analysis Used:SPSS version 16 was used. Percentages, means, and standard deviations were measured. Chi square, t, and Fisher's exact tests were applied.Results:Correct drug choice, dose, dosage form, route of administration were significantly higher in the clinic adopting IMCI {clinic B} (89.3%, 87.3%, 91.3%, and 91.3%, respectively) than in the clinic not adopting it {clinic A} (78% each). Non pharmacological remedies prescribed were significantly higher in clinic B than A (64.7% vs 4.6%). Average no of drugs/ encounter was lower in clinic B than A (0.93± 0.2 vs 1.37 ± 0.6) and the difference between clinics was statistically significant. Difference between clinics regarding percentages of drugs prescribed by generic name, antibiotics prescribed, drugs prescribed from essential drug list, and drugs prescribed out of stock was significant.Conclusion:Adopting IMCI strategy improved prescribing performance and treatment regimen.

Syndromic Diagnosis of Malaria in Rural Sierra Leone and Proposed Additions to the National Integrated Management of Childhood Illness Guidelines for Fever

Many countries in Africa, including Sierra Leone, have adopted artemisinin-based combination therapy as first-line therapy for treatment of patients with malaria. Because laboratory testing is often unavailable in rural areas, the cost-benefit and viability of this approach may depend on accurately diagnosing malaria by using clinical criteria. We assessed the accuracy of syndromic diagnosis for malaria in three peripheral health units in rural Sierra Leone and determined factors that were associated with an accurate malaria diagnosis. Of 175 children diagnosed with malaria on syndromic grounds, 143 (82%) were confirmed by the Paracheck-Pf test. In a multivariate analysis, splenomegaly (P = 0.04) was the only clinical sign significantly associated with laboratory-confirmed malaria, and sleeping under a bed net was protective (P = 0.05). Our findings show that clinical malaria is diagnosed relatively accurately in rural Sierra Leone. Incorporating bed net use and splenomegaly into the national Integrated Management of Childhood Illness guidelines for evaluation of fever may further enhance diagnostic accuracy for malaria.

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

Incidence of pneumonia and gastroenteritis among infants admitted to Orotta Referral Paediatric Hospital in Asmara, Eritrea in 2006.

A retrospective study based on medical records of infants admitted to the Orotta Paediatric Teaching Hospital for the whole of 2006 in order to study the morbidity and mortality rates from pneumonia and gastroenteritis among infants in Eritrea using the integrated management of childhood illnesses guidelines. The main causes of the 2537 admissions of whom nearly two thirds were males and which showed no seasonal variation were pneumonia (39.7%), gastroenteritis with no dehydration (27.1%) and severe pneumonia (19.7%). The case fatality rates were 1.6% for severe pneumonia, 2.7% for pneumonia, 3.5% for gastroenteritis, and 3.2% for those affected by pneumonia and gastroenteritis. Relatively high infant morbidity rates in this study from pneumonia and gastroenteritis is mitigated by low case fatality rates. There is urgent need to identify the factors underpinning high morbidity among infants and scale up interventions such as community IMCI. Key words: Pneumonia, gastroenteritis, IMCI, Orotta, Eritrea.

Quality Assurance of Rapid Diagnostic Tests for Malaria in Routine Patient Care in Rural Tanzania

Histidine-rich protein II (HRP2)-based malaria rapid diagnostic tests (RDTs) have shown high sensitivity and specificity for detecting Plasmodium falciparum malaria in a variety of study settings. However, RDTs are susceptible to heat and humidity and variation in individual performance, which may affect their use in field settings. We evaluated sensitivity and specificity of RDTs during routine use for malaria case management in peripheral health facilities. From December 2007 to October 2008, HRP2-based ParaHIT-f RDTs were introduced in 12 facilities without available microscopy in Rufiji District, Tanzania. Health workers received a single day of instruction on how to perform an RDT and thick blood smear. Job aids, Integrated Management of Childhood Illness guidelines, and national malaria treatment algorithms were reviewed. For quality assurance (QA), thick blood smears for reference microscopy were collected for 2 to 3 days per week from patients receiving RDTs; microscopy was not routinely performed at the health facilities. Slides were stained and read centrally within 72 hours of collection by a reference microscopist. When RDT and blood smear results were discordant, blood smears were read by additional reference microscopists blinded to earlier results. Facilities were supervised monthly by the district laboratory supervisor or a member of the study team. Ten thousand six hundred fifty (10,650) patients were tested with RDTs, and 51.5% (5,488/10,650) had a positive test result. Blood smear results were available for 3,914 patients, of whom 40.1% (1,577/3,914) were positive for P. falciparum malaria. Overall RDT sensitivity was 90.7% (range by facility 85.7-96.5%) and specificity was 73.5% (range 50.0-84.3%). Sensitivity increased with increasing parasite density. Successful implementation of RDTs was achieved in peripheral health facilities with adequate training and supervision. Quality assurance is essential to the adequate performance of any laboratory test. Centralized staining and reading of blood smears provided useful monitoring of RDT performance. However, this level of QA may not be sustainable nationwide.

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

BackgroundPneumonia 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.MethodsWe 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.ResultsWe 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: 1.1-3.9] per additional supervisory visit).ConclusionIntegrated 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).