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5e. Child Health: Interventions to Improve the Management of Children Diseases - 2
Multifaceted Intervention to Improve Health Worker Adherence to Integrated Management of Childhood Illness Guidelines 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; 4Division of General and Community Pediatric Research, Cincinnati Children’s Hospital, USA
Problem statement: The World Health Organization’s Integrated Management of Childhood Illness (IMCI) strategy aims to improve child health in developing countries by encouraging use of evidence-based guidelines for managing the leading causes of child mortality. Although studies have showed that training health workers on IMCI guidelines can improve the quality of care at health facilities, these studies also revealed substantial room for improvement in adherence to the guidelines.
Objective: Evaluate an intervention to support health workers after IMCI training
Design: Randomized trial; in 1999, we assessed health care quality before IMCI training with a health facility survey that involved observing consultations, re-examining patients, and interviewing caretakers and health workers. Follow-up surveys were conducted in 2001, 2002, and 2004.
Setting: 130 public and licensed private outpatient health facilities in 16 districts in southeastern Benin
Study population: Ill children <5 years old seen at health facilities and the health workers who performed the consultations
Intervention: Health workers received standard 11-day IMCI training plus either usual supports (control group) or a package of study supports that included job aids (IMCI patient register and a counseling guide), nonfinancial incentives (framed certificate of merit distributed at a ceremony), and supervision of workers and supervisors.
Outcome measures: Children with a potentially life-threatening illness (PLTI; e.g., malaria or pneumonia) who received recommended treatment; children with a PLTI who received recommended or adequate treatment; and for all children, an index of overall guideline adherence (percentage of all IMCI-recommended tasks that were performed)
Results: We analyzed 1,244 consultations performed by 267 health workers; 1,101 children had a PLTI. Performance improved in both intervention and control groups with no significant differences between groups. However, training proceeded slowly, and low-quality care from health workers without IMCI training diluted intervention effects. Per-protocol analyses revealed that workers with IMCI training plus study supports provided better care than did those with training plus usual supports for all 3 outcomes, ranging from an improvement of 15–27 percentage points. Additionally, IMCI-trained health workers outperformed non-IMCI-trained workers for all 3 outcomes by 19–50 percentage points. All results but one were statistically significant (p < 0.05). Compared with usual supports, study supports cost USD 0.58 per additional child with a PLTI receiving recommended treatment (95% confidence interval: USD 0.36–1.46).
Conclusions: IMCI training was useful but insufficient. Relatively inexpensive supports can lead to additional improvements. This study was published in the American Journal of Public Health (2009; 99:837–846).
Funding source: United States Agency for International Development
Unnecessary Antibiotic Use for Mild Acute Respiratory Infections in a 28-Day Follow-Up of 823 Children Under Five in Rural Vietnam
1Hanoi Medical University, Viet Nam; 2Vietnam Cuba Hopsital, Hanoi, Vietnam; 3Institute of Mathematics, Hanoi, Vietnam; 4Karolinska Institutet, Stockholm, Sweden; 5Nordic School of Public Health, Gothernburg, Sweden
. Problem statement: Few prospective studies about antibiotic use for mild acute respiratory infections (ARIs) have been conducted in community settings.
Objectives: To assess knowledge of children’s caregivers and actual antibiotic use for children under 5 and to identify associated factors with antibiotic treatment for mild ARIs.
Design: Caregivers in 828 households in Bavi, Vietnam, were interviewed using a structured questionnaire regarding the case management of childhood ARI and the selected children’s most recent illness assessing both knowledge and practice. Then 823 children were followed for 28 days to collect information regarding symptoms and drug use.
Setting: The study setting was Bavi district, 60 km west of Hanoi, where an Epidemiological Field Laboratory (Filabavi) was implemented in 1998. The district covers an area of 410 km2, divided into lowland, highland, and mountainous areas according to geographical characteristics.
Study population: The sample of 847 children ages 6–60 months was obtained from 847 households in 13 clusters within the Filabavi framework to investigate Streptococcus pneumoniae susceptibility from their nasopharyngeal samples.
Results: For nonfebrile common colds, 85% of caregivers stated correctly that antibiotics are not required. For febrile colds and pneumonia, 45% and 47%, respectively, stated that they would require antibiotics. Only 13% demonstrated correct overall knowledge that was in accordance with standard guidelines for all three situations. The symptoms of the most recent illness were consistent with mild ARI in 79% of the cases, and antibiotics were used in 71% of these. During the 28-day period, 62% of children had been given antibiotics. Out of all antibiotic courses recorded, 63% were used for mild ARIs. Half of the mild ARI episodes (528/1048) and 63% of the children with mild ARIs (392/623) were treated with antibiotics. Limitations: We collected data based on structured interviews with children’s caregivers without clinical examination. Furthermore, we did not collect information about the expectations of the parents of receiving antibiotics when seeking care, though this might influence the prescribing pattern of health providers.
Conclusion: Most of the children had been administered antibiotics for common colds although most caregivers believed that antibiotics were not required. Antibiotics were unnecessarily recommended at health facilities in the area.
Funding source(s): Health Systems Research Project, funded by Sida/SAREC, Sweden and the Ministry of Science and Technology, Vietnam.
Promoting Proper Use of Medicines in School Children: An Interventional Study
GOVERNMENT MEDICAL COLLEGE, NAGPUR, MAHARASHTRA, INDIA., India
Problem statement: People use medicines not as per doctors’ direction, but per their own will. For safe and proper use of medicines, the proper way of taking medicines must be understood. Teaching proper use of medicines is the most neglected domain of the school health curriculum, especially in developing economies. Children mainly gain knowledge about medicine use by observing health practices of their parents. Also, many advertisements by pharmaceutical companies mainly target school children because they can influence their parents to buy medicines. So, this study targeted school children, because the earlier the intervention—teaching them about proper medicine—the longer lasting, health-related behavior can be successfully inculcated into them.
Objectives: To study the base level knowledge about use of medicines in school children; implement an intervention in the form of information, education, and communication (IEC) to increase medicine knowledge among school children; and see the effect of IEC on the awareness about proper use of medicines in school children
Design: This was an interventional, questionnaire-based (qualitative) study in which the level of awareness about the proper use of medicines in school children was compared before and after giving an intervention in the form of lectures to the children.
Setting: This study was conducted at local level; children in IXth and VIIIth standard were selected from 3 different schools of Nagpur.
Study population: The data was collected from 500 school children after obtaining permission and informed consent from the school authorities.
Interventions: After explaining about the research project to the children, pretesting was done by administering a questionnaire containing 24 questions to assess the children’s base level knowledge about medicine use. Teaching material related to rational use of medicines was distributed to teachers who were requested to teach children daily for 15-30 minutes for 1 week. After a week, a one-hour lecture on rational use of medicine was given to the children and the same questionnaire was again administered to judge the improvement.
Results: It was observed that the interventions brought about a positive change in the knowledge of the students as well as increased awareness about proper use of medicines.
Conclusion: This study showed that a properly timed and meticulously implemented intervention can bring about a positive change in the attitude and knowledge of school children.
Funding source: This study was not funded by any funding agency.
Cost and Cost-Effectiveness of Training Zambian Traditional Birth Attendants in Interventions Targeting Common Causes of Neonatal Mortality
Boston University School of Public Health, United States of America
Problem statement: The Lufwanyama Neonatal Survival Project was a randomized controlled effectiveness trial that showed that training traditional birth attendants (TBAs) to perform interventions targeting birth asphyxia, hypothermia and neonatal sepsis reduced all causes of neonatal mortality by 45% (relative risk 0.55, 95% confidence interval 0.33 to 0.90). The interventions consisted of (1) training TBAs in a simplified neonatal resuscitation protocol algorithm and (2) identification of sepsis, initiation of amoxicillin, and facilitated referral to a health center.
Objective: This companion analysis was conducted to assess the costs and cost-effectiveness of this package of interventions.
Methods: We calculated the intervention’s financial and economic costs, the economic cost of implementing a modified model of the intervention over a future 10-year period (2011–20), and the incremental cost-effectiveness of deaths avoided and disability-adjusted life years (DALYs) saved for both the 2.5 years of the actual program and the projected 10-year scenario to model the interventions if used programmatically. Sensitivity analysis was conducted for the economic cost-effectiveness outcomes of the 10-year program.
Results: Total financial and economic costs of the intervention were $106,271 and $114,998, respectively, in real 2006 US dollars, or $47,232 and $51,110 on an annualized basis. Fixed costs were responsible for close to 90% of total costs. Total and annualized costs in 2011 US dollars of the 10-year program were $258,076 and $25,808, respectively. For the 10-year program, the estimated cost per DALY saved was $29.52, and the cost to have a trained TBA at each delivery was $11.30. Sensitivity analysis indicated that outcomes were most sensitive to variations in the effectiveness of the interventions, the extent to which expensive foreign consultants were used, the average number of births conducted per TBA per year, and the number of program TBAs per training workshop.
Conclusions: This simple package of interventions was highly cost-effective. We believe that this is a highly generalizable model for reducing neonatal mortality for populations with limited access to health care.
Funding source(s): Information not provided