RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate and address (in block letters) / MR.ADIL ABDUL RAHMAN1st YEAR MSc NURSING
EAST WEST COLLEGE OF NURSING
BANGALORE
2. / Name of the Institution / EAST WEST COLLEGE OF NURSING
BANGALORE
3. / Course of Study and Subject / M. Sc. NURSING
PAEDIATRIC NURSING
4. / Date of Admission to the Course
5. / Title of the study: / “EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING INTEGRATED MANAGEMENT OF CHILD ILLNESS STRATEGY AMONG NURSES IN HOSPITALS, BANGLORE”.
6. A BRIEF RESUME OF THE INTENDED WORK.
6.1 INTRODUCTION:
IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities.
The strategy includes three main components:
· Improving case management skills of health-care staff
· Improving overall health systems
· Improving family and community health practices.
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 counselling of caretakers, and speeds up the referral of severely ill children. In the home setting, it promotes appropriate care seeking behaviours, improved nutrition and preventative care, and the correct implementation of prescribed care. The Integrated Management of Childhood Illness (IMCI) was introduced by UNICEF and WHO in 1995 as a new strategy aiming at reducing the continuing high morbidity and mortality in children under the age of five years. This integrated strategy led to the formation of "The Integrated Management of Childhood Illness (IMCI)" in 1992 by UNICEF and WHO. It was based on the rationale that decline in child mortality rates is not necessarily dependent on the use of sophisticated and expensive technologies but rather on a holistic approach that combines the use of strategies that are cheap and can be made universally available and accessible to all. According to the World Bank Report 1993, for situations where laboratory support and clinical resources are limited, such an approach is more realistic and cost-effective, and therefore, has the potential to make the greatest impact on the global burden of disease6.
6.2 NEED FOR THE STUDY
The need for this study is 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. Pneumonia, diarrhea, malaria, measles and malnutrition account for over 70% of the 11.5 million deaths and 80-90% of sick child consultations in developing countries. These conditions often occur in combinations requiring a holistic approach of assessment, treatment and caretaker counseling Children brought for medical treatment are often found suffering from more than one morbid condition, making a single diagnosis impossible. These children require a combined therapy for successful treatment. Thus, the need of the hour is an integrated strategy that combines the treatment of major childhood illnesses, with involvement of parents in provision of home-based care, prevention of disease through immunization, improved nutrition, and breast feeding An evaluation of IMCI strategy in 12 countries over the world revealed that the training of healthcare workers improved the quality of care significantly. This strategy has now been implemented in more than 100 countries5 .
In India, there are nearly 17 lakh child deaths each year, and child mortality rates are one of the highest in the world. The Government of India recognized the need to strengthen child-health activities in the country and decided to launch IMCI. A core group was constituted comprising representatives from Indian Academy of Paediatric (IAP), National Neonatology Forum of India (NNF), National Anti-Malaria Program (NAMP), Department of Women and Child Development (DWCD), Child-in Need Institute (CINI), WHO, UNICEF, eminent Pediatricians and Neonatologists and the representatives from the Ministry of Health and Family Welfare (MOHFW), and the Government of IndiaAlthough the annual number of deaths among children less than 5 years old has decreased by almost a third since the 1970s, this reduction has not been evenly distributed throughout the world. According to the 1999 World Health Report, children in low- to middle-income countries are 10 times more likely to die before reaching age 5 than children living in the industrialised world. In 1998, more than 50 countries still had childhood mortality rates of over 100 per 1,000 live births.
Every year more than 10 million children in these countries die before they reach their fifth birthday. Seven in 10 of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition — and often to a combination of these conditions
Child health programmes need to move beyond single diseases to addressing the overall health and well-being of the child. Because many children present with overlapping signs and symptoms of diseases, a single diagnosis can be difficult, and may not be feasible or appropriate. This is especially true for first-level health facilities where examinations involve few instruments, little or no laboratory tests, and no X-ray1.
During the mid-1990s, the World Health Organization (WHO), in collaboration with UNICEF and many other agencies, institutions and individuals, responded to this challenge by developing a strategy known as the Integrated Management of Childhood Illness (IMCI). Although the major reason for developing the IMCI strategy stemmed from the needs of curative care, the strategy also addresses aspects of nutrition, immunization, and other important elements of disease prevention and health promotion. The objectives of the strategy are to reduce death and the frequency and severity of illness and disability, and to contribute to improved growth and development.
The IMCI clinical guidelines target children less than 5 years old — the age group that bears the highest burden of deaths from common childhood diseases
The World Health Organization, UNICEF and other technical partners have developed The Integrated Management of Childhood Illness (IMCI) strategy to reduce child mortality and improve child health and development through a holistic approach. By the end of 2002, 109 countries among which 17 in the region of the Americas and Caribbean had adopted and implemented this strategy,. Haiti presents the highest mortality rate for under-fives. Every year, more than 138,000 children die of diseases such as malaria, pneumonia, diarrhea, measles and perinatal complications. It is recognized that the mortality due to these diseases can be prevented6.
6.3 CONCEPTUAL FRAME WORK
The conceptual frame work selected for the study was based on’’ ERNESTINE
WEIDENBACH’’ prescriptive theory.
6.4 REVIEW OF LITERATURE
Here the investigator has gone through previous studies and research papers which are related to the study :
An evaluative study was conducted in Haryana , India to study 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 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. Thus the conclusion was that 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 worker1
A descriptive study that determines the technical basis for the guidelines for the
integrated management of childhood illness (IMCI), which are presented in the
WHO/UNICEF training course on IMCI for outpatient health workers at first-level health
facilities in developing countries. These guidelines include the most important case management and preventive interventions against the leading causes of childhood mortality--pneumonia, diarrhoea, malaria, measles and malnutrition. The training course
enables health worker use the guidelines to make correct decisions in the management
of sick children. The guidelines have been refined through research studies and field-
testing in the Gambia, Ethiopia, Kenya, and United Republic of Tanzania, as well as
studies on clinical signs in the detection of anaemia and malnutrition. These studies, and
two others from Uganda and Bangladesh, are presented in this Supplement to the
Bulletin of the World6
A Study was conducted to assess the effectiveness of IMCI skills in Health workers. 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. 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.. Health 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 investigation7
The Integrated Management of Childhood Illness is a strategy designed to address major causes of child mortality. The aim of this study was to assess the impact of the strategy on the quality of child health care provided at primary facilities. Child health quality of care and costs were compared in four states in Northeastern Brazil, in 2001. There were studied 48 health facilities considered to have had stable strategy implementation at least two years before the start of study, with 48 matched comparison facilities in the same states. A single measure of correct management of sick children was used to assess care provided to all sick children. Costs included all resources at the national, state, local and facility levels associated with child health care. Facilities providing strategy-based care had significantly better management of sick children at no additional cost to municipalities relative to the comparison municipalities. At strategy facilities 72% of children were correctly managed compared with 56% in comparison facilities (p=0.001). The cost per child managed correctly was US$13.20 versus US$21.05 in the strategy and comparison municipalities, respectively, after standardization for population size. The strategy improves the efficiency of primary facilities in Northeastern Brazil. It leads to better health outcomes at no extra cost8 .
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 .Health workers found the training interesting, informative and empowering, and there was consensus that it improved their skills in managing sick children. 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 barrier2.
A study conducted in Ethiopia for the development of IMCI within the region in 1997. This analytical review has been made to identify ways to strengthen and sustain IMCI implementation. The review identified that most of the childhood deaths and 40% of all disability-adjusted life years lost are associated with pneumonia, diarrhea, malaria, measles and malnutrition. IMCI has, thus, been adopted in 1997 as the main strategy for improving child health.. A standardized checklist needs to be developed and integrated into existing supervision protocols and this be used to supervise IMCI implementing facilities regularly. Strategies to train and involve lower level health cadres in IMCI implementation and modify the standard IMCI course to suit senior physicians and programme managers are required. Standard recording and reporting tools need to be developed and IMCI classifications harmonized with current MOH guidelines. Essential IMCI drugs should be available to health facilities. Interventions need to be identified and tools developed to support the IMCI implementation at community and family level4.
At a clinic in Benin, a study clinician performed counselling and confirmed caretakers'comprehension of all messages. Caretakers were randomly assigned to be interviewed either immediately after the consultation or a day later. Recall was assessed with general and focused open-ended questions. Recall was assessed for 55 caretakers, 29.1% of whom were literate. Caretakers received 3-75 messages (mean = 38.7). The mean percentage of messages recalled was 89.7% immediately after the consultation and 81.9% one day later. These results support IMCI's recommendation that health workers should verify caretakers' comprehension by asking caretakers to repeat counselling messages during consultations5