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4e. Child Health: Interventions to Improve the Management of Children Diseases - 1
The Rise and Fall of Supervision in a Project Designed to Strengthen Supervision on the Integrated Management of Childhood Illness (IMCI) Strategy in Benin
1U.S. Centers for Disease Control and Prevention, United States of America; 2Direction Départementale de la Santé Publique de l’Ouémé et Plateau, Benin Ministry of Health; 3Africare-Benin, Porto Novo, Benin
Problem statement: In developing countries, supervision is a widely recognized strategy for improving health worker performance; and anecdotally, maintaining regular, high-quality supervision is difficult. However, there has been little in-depth research to explore why supervision is so challenging.
Objective: During a trial to improve health worker adherence to IMCI guidelines and strengthen supervision, we studied the supervision process and identified contextual factors associated with strengths and weaknesses.
Design: Case study from 2001–2004 with prospective data collection via record reviews, focus group discussions, key informant interviews, and cross-sectional surveys
Setting: 130 outpatient health facilities in southeastern Benin
Study population: District supervisors and their superiors
Interventions: First, a 1-week workshop with supervisors to design (1) a supportive supervision protocol that recommended 2 supervision contacts with health workers every 3 months, (2) a supervision checklist, and (3) supervision of supervisors by a senior pediatrician to improve technical and interpersonal skills. Second, short workshops (1–3 days) held quarterly for planning and problem-solving.
Outcome measures: Percentage of planned supervision visits of IMCI-trained workers that actually occurred
Results: Initially, little supervision occurred. The frequency increased substantially after implementing the quarterly workshops, but then deteriorated. Quantitative and qualitative data revealed obstacles to supervision at multiple levels of the health system. Based on supervisors’ opinions, the main problems were poor coordination; inadequate management skills and ineffective management teams; a lack of motivation; problems related to decentralization; occassional resistance by health workers to IMCI implementation; and less priority given to IMCI supervision because of incentives for nonsupervision activities, a lack of leadership, and an expectation of integrated supervision. To this list, based on our observations, we add the increasing supervision workload, time required for nonsupervision activities, project interventions not always implemented as planned, and the loss of particularly effective supervisors. In terms of correctly completing steps of the supervision process, the quality of supervision was generally good.
Conclusions: Managers should monitor supervision, understand the evolving influences on supervision, and use their resources and authority to both promote and remove impediments to supervision. Support from leaders can be crucial; donors and politicians should thus help make supervision a true priority. As with front-line clinicians, supervisors are health workers who need support. We emphasize the importance of research to identify effective and affordable strategies for improving supervision frequency and quality. This study was published in Health Policy and Planning (2010; 25:125–134).
Funding source: USAID
Impact of Pharmacist’s Roles on Reducing Readmission Rate and Promoting Patient Safety in Pediatric Cardiac Patients
Siriraj Hospital, Mahidol University, Thailand, Thailand
Problem Statement: In the year 2008, there were two serious cases of medication errors in a hospital’s pediatric cardiac patients—one of them was readmitted. A multidisciplinary team suggested pharmacists perform discharge counseling and medication reconciliation program for these vulnerable patients.
Objectives: To study the characteristics of drug-related problems (DRPs) throughout discharge counseling and medication reconciliation process and its impacts on readmission rate and patient safety.
Design: Observational descriptive study
Setting: Pediatric cardiac ward in Siriraj Hospital, the 2,300 beds tertiary-care teaching hospital of Mahidol University, Thailand.
Study population: Every patient who was admitted during October, 2009 to October, 2010 was screened by ward nurses. Only 9 high risk patients were enrolled to the study from one of the inclusion criteria
: (1) first time received cardiovascular drugs as home medication; (2) received new item(s) of high alert drugs as home medication; (3) prone to have drug-related problems (DRPs) from limitations of age, race, and illiteracy; or (4) had previous DPRs that attributed to a current readmission.
Intervention: The pharmacists identified DRPs by chart reviews and patient or caregiver interviews. Discharge counseling was planed and done by several educational materials. All DRPs were resolved based on patients’ needs. The pharmacist made the first phone call one week after discharge and every 2 weeks or more. At a visit date, pharmacist reassessed DRPs and reconciled the medication lists.
Policy: Pharmaceutical cares by pharmacists were provided for vulnerable chronic disease patients.
Outcome measures: Number of the pharmacist’s activities, identified DRPs and readmission rate
Results: From 9 enrolled patients, average of 8.3 home medication items per patient, there were 258 pharmacist activities and 99 DRPs were identified. All detected DRPs were resolved before resulting in harm to patients. DRPs were mostly found by patient chart reviews and patient or caregiver interviews (43.4%) and by phone calls (35.4%). The top three identified DRPs were non-adherences (52.5%), medication errors (18.2%) and inappropriate administration skills (17.2%). Only one patient (11.1%) was readmitted from her depressive disorder.
Conclusion: The pharmacist’s activities could prevent readmission from non-adherences and medication errors. Early DRPs detection and resolving could generate more patient safety in vulnerable chronic disease patients.
Funding Source: ICIUM scholarship
Effectiveness of Oral Zinc Supplementation in the Treatment of Acute, Watery Diarrhea
Faculty of Medicine, Suez Canal Univeristy, Egypt
Problem statement: Oral rehydration solution (ORS) has been successfully used around the world and has been responsible for reduction of diarrheal deaths in the last 2 decades. In spite of the success of ORS in prevention of dehydration, there is still a demand for medicines that will reduce the duration and severity of diarrhea. Consequently, many cases are treated with antibiotics and other medicines. Zinc has been shown to be efficacious in reducing the duration of diarrhea and associated mortality.
Objective: To determine the effectiveness of oral zinc supplementation with locally developed, culturally specific educational messages in the treatment of acute watery diarrhea; to assess adherence to zinc therapy, the impact of zinc therapy on the duration of diarrheal episodes, the use of ORS, and the usage of antibiotics and/or “antidiarrheal” medicines
Design: Randomized, controlled effectiveness trial
Setting: Four primary health centers in Ismailia governorate, Egypt
Participants: 412 children aged 2-60 months were enrolled in the study; 222 children received zinc therapy and 190 were controls. Mean age of the recruited children was 16.9+12.5 months
Methodology: Children with diarrhea in the intervention group were treated with zinc sulfate (20 mg/day once daily for 14 days) and ORS, while children in the control group were treated with ORS alone. The primary outcome measurements were the duration of diarrheal episodes, acceptability of zinc by the treated children, ORS use, and the use of antibiotics or “antidiarrheal” medications.
Results: The study showed high adherence to zinc therapy, as 73% of the children consumed more than 80% of the zinc effervescent tablets. The results showed that zinc supplementation caused significant reduction in the duration of diarrheal episodes of about 24% in the zinc-treated group. The study also showed significant reduction in the use of antidiarrheals and/or antibiotics use rate in the zinc study group compared to controls (7.7% vs. 20.6%). Frequency of ORS use during diarrheal episodes was the same in the 2 study groups.
Conclusions: Oral zinc supplementation, in under-5 children suffering from acute watery diarrhea, is efficacious in reducing the duration of diarrheal episodes and in reducing the maluse of “antidiarrheals” and antibiotics, with no decrease in the frequency of ORS use. Children showed good adherence and acceptance to zinc therapy without considerable side effects.
Funding source: USAID-CHR, Washington (via INCLEN Trust) and Johns Hopkins University
Effect of Multiple Micronutrient Supplements for Improving Anaemia of Preschool Age Children in Rural, Lao People’s Democratic Republic: A Randomized Trial
1National Institute of Public Health, Ministry of Health, Lao People's Democratic Republic; 2Department of International Health, Institute of Tropical Medicine (NEKKEN) and the Global Centre of Excellence Program (GCOE), Nagasaki University, Japan; 3Research Institute for Humanity and Nature, Kyoto, Japan
Problem statement: Multiple micronutrient deficiencies, in particular anaemia, constitute a severe public health problem in the Lao People’s Democratic Republic (Lao PDR) because of the limitations associated with the use of liquid iron supplements for the treatment and prevention of iron deficiency anaemia in infants and young children. The Ministry of Health Lao PDR approved a low-cost strategy to deal with this problem—a home fortification with multiple micronutrient powder (MMP) sprinkles. Sprinkles have been shown to be efficacious in the treatment of anaemia in many developing countries, but the effectiveness of micronutrient supplementation depends on the local food culture and acceptance by the people. It was unknown how this approach would work in Lao PDR. Therefore, the effectiveness of MMP sprinkles needed to be tested to clarify optimal starting points and duration of supplementation based on individual status or population prevalence.
Objective: To compare the effects of twice weekly supplementation (TWS) and daily supplementation with MMP in improving anaemia, haemoglobin concentration, and growth among infants and young children in a rural community of Lao PDR. We also assessed the compliance and acceptability of MMP.
Methods: A randomized trial was conducted in 6 rural communities in Savannakheth province, Lao PDR. Children ages 6 to 52 months (n=336) were randomly assigned to either a control group (n=110) or one of two intervention groups (either receiving two sachets per week (TWS) (n=115) or a daily sachet (n=111) supplementation of MMP for 24 weeks; 331 children completed the study. A finger prick of blood was taken at baseline, week 12, and week 24 to determine haemoglobin concentration. Anthropometric measurements were taken every 4 weeks. Compliance was assessed weekly by counting used sachets and acceptability was assessed at the end of the intervention.
Results: After weeks 12 and 24, MMP supplementation resulted in significant improvements in haemoglobin concentration and reduction in anaemia prevalence in the two treatment groups compared with the control group (p<0.001). The severe to moderately anaemic children (Hb <100 g/L) recovered more quickly through daily supplementation than by TWS. MMP sprinkles were well accepted, and compliance was high in both treatment groups. Overall, improvement was observed in the weight for age Z-score among three study groups.
Conclusions: MMP supplementation had positive effects in the reduction of anaemia prevalence and in improving haemoglobin concentration. For severe to moderate anaemic children daily MMP supplementation was more effective in improving haemoglobin concentration and in reduction in anaemia prevalence. A longer intervention period would be needed to have a positive impact on growth.
Keywords: Anaemia, multiple micronutrient powder, supplementation, preschool-age children, Lao PDR
Ethical approval: Ethical approval for this study was obtained from the Nagasaki University Ethical Review Board (Japan) and the National Ethic Committee for Health Research of the Ministry of Health (Lao PDR).
Funding: This study was conducted as a part of the Eco-Health project of the Research Institute for Humanity and Nature, Kyoto (Japan) in collaboration with the National Institute of Public Health, Lao PDR. Sengchanh Kounnavong received funding from the Asian Health and Education Fund, Tokyo (Japan) and partly of the Institute of Tropical Medicine, Nagasaki University (NEKKEN) Fellowship.