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The National Ribat University

Competent collage

Faculty of Nursing Science

Assessment Efficiency of IMCI training

Of nurses Ribat teaching hospital

A research thesis Submitted in partial fulfillment for the requirement of

Master Degreein pediatric nursing science

By:ZINAB DAFF ALLA ALAMIN MOHMED

Supervisor:Dr.AbdalmageedOsmanMusa

Associated prof in Africa University

2015

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To our mothers &our fathers

To our lovely sisters & our brothers

To our teachers & colleagues.

To candles that burn to illuminate for others

Who supported us in every moment

Of our humble thesis & we hope to find

Acceptance and success.

(II)

I indebted to

Dr/Abdalmageed Osman Musa

, for her help, supervised, and

Encouragement all over the time

of our study. Also we wish to acknowledge

The medical director, matron for their permission

Thanks are due to our families

Who support us. Our acknowledge

Is extended to our colleges in al Ribat

University hospital (nurses) for their

Cooperation during data collection.

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LISTE OF CONTENTS

Title Page

Dedication I

Acknowledgement II Table of contents III -IV

English abstracts V

Arabic abstract VI

List of figures VII

List of tables VIII

List of abbreviations IX

Chapter one

1.1Introduction 1 1.2Statement of problem 1

1.4Objectives 2

Chapter Two

2. Literature review and previous studies 3-8

Chapter Three

3. Methodology 9

3.1 Study Design 9

3.2 Study Area 9

3.3Study Period 9

3.4 study population 9 3.5 sample size 9 3.6 Data collection tools 9 3.7Data collection methods 9 3.8Data analysis 9 3.9 Ethical consideration 9

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Chapter Four

4.Results

10-15

Chapter Five

5.1 Discussion 16

5.2Conclusion 17

5.3 Recommendations 18

5.4 References 19

Appendix

Questionnaire and check list

I

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Abstract

Assessment Efficiency of IMCI training of nurses Ribat teaching

hospital.

Background: Integrated management of childhood illness (IMCI)

was introduced in Sudan in 1996 as a strategy to address the most

important causes of under-five mortality and morbidity using an

integrated approach in line with the primary health care policy. It has

since expanded to cover about 500 health facilities in 71 (30%) out of

240 districts located in 10 States. This survey was planned to measure

outcome indicators on quality of care at IMCI health facilities

This is a cross -sectional descriptive study hospital base on

nurses in Ribat teaching hospital from Aug2014-Feb 2015.

50 nurses were chosen representing a mixture of diploma,

bachelors and master holder as a total coverage sample ,data was

collected by using (50) structured designed questionnaire to assess

efficiency of IMCI training program for nurses and focus group

discussion ,and analyzed by statistical package for social sciences

(SPSS) computer program.

The aim of this study to assess the efficiency of IMCI training

program ,to assess knowledge of nurses in integrated management of

child health and to assess the prevalence of trained nurses in IMCI and

to assess the concepts of nurses regarding IMCI.

The research contain background, introduction problem

statement objective, methodology, and objective of the research,

literature review include definition of IMCI, How implemented of

IMCI, implemented in Sudan and previous study of IMCI

With methodology, and data result and analysis, and finally

discussion conclusion and recommendation.

(VI)

Among (50) a participant in the study it was found that most of the

nurses had a bachelor’s degree 92% as most of them had a working

period of not more than 5 years. 58%of the nurses had an experience

of 4-5y without any training in IMCI (table no 2).The theoretical course

seems to be Short as 58% of the nurses believe. Result about the

efficiency for the course showing dissatisfaction of most of the nurses

(table no 6).

The conclusion there is a deficiency in the practical training;

almost most of the nurses (62%) did not attended Practical training in

IMCI at the level of community health centers or hospital.

The Recommendation revision of IMCI course objectives and

contents, enough time should be allocated for IMCI, enough time

should be allocated for the practical part of the course and enough staff

of training teacher.

(VII)

المستخلص

كإستراتيجية ميمة لمعرفة أسباب 6991بدأ العالج المتكامل لالطفال في السودان في عام سنوات وذلك باستخدام قواعد الرعاية 5ال الذين تبمغ أعمارىم أقل من المرض والوفيات لدى األطف

واليات في السودان. 65مرفق صحي في المناطق الواقعة في 555الصحية األولية وتمدد ليغطي

يعتبر ىذا البحث دراسة قطاع عرضي ووصفي لمممرضات في مستشفي الرباط الجامعي في وىى تمثل خميط من الممرضات حممة الدبموم 7565فبراير -7562الفترة من اغسطس

إستبيان لتقييم كفاءة ( 55) والبكالوريوس وماجستير التمريض وقد تم جمع البيانات بإستخداملمتكامل ألمراض الطفولة لمممرضين والممرضات ومجموعة مناقشة صغيرة وتحميميا برنامج التدريب ا

.SPSSبواسطة برنامج الحزم اإلحصائية لمعموم اإلجتماعية

اليدف من ىذه الدراسة ىو تقييم كفاءة برنامج التدريب المتكامل ألمراض الطفولة وتقييم معرفة لصحة الطفولو وعدد الممرضات المدربات في العالج الممرضات فيما يتعمق بالعالج المتكامل

المتكامل ألمراض الطفولة ومعرفو مفيوم الممرضات لمعالج المتكامل لمطفولة.

٪97 أظيرت الدراسة أن معظم الممرضات يحممن درجةالبكالوريوس، إذ بمغت نسبتين سنوات دون أي تدريب 5-4من الممرضات لديين خبرة ٪ 55.سنوات 5 وسنوات خبرتين أقل من

من الممرضات يعتقدن بأن الجانب النظري لمدورة ٪ 55 في العالج المتكامل ألمراض الطفولةوالتدريبية غير كافي لقصر الفترة وعميو يمكن القول بأن ىناك نقص في التدريب العممي حيث ان

اض الطفولة عمى لم يحضرن التدريب العممي في العالج المتكامل ألمر ٪( 17) معظم الممرضات مستوى مراكز صحة المجتمع أوالمستشفى.

نوصي بمراجعة أىداف ومحتويات العالج المتكامل ألمراض الطفولة كما ينبغي تخصيص وقت كافي لمعالج المتكامل ألمراض الطفولة وكذا الحال بالنسبة لمجزء العممي من الدورة وتوفير عدد

في المجال الطبي)الممرضين(. كافي من المدربين لتدريب العاممين

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List of abbreviation

IMCI integrated management of child illness

WHO world health organization

UNICFE united nation of children funds

PHC primary health care

HIV human immune deficiency virus

CNP clinical nurses practionor

EMRO Eastern mediterrean regional office

FMOH Federal ministry of heath

SPSS statistical package for social sciences

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CHAPTER ONE

Introduction

Background

Integrated management of childhood illness (IMCI) was introduced in Sudan in 1996 as

strategy to address the most important causes of under-five mortality and morbidity using

an integrated approach in line with the primary health care policy. It has since expanded

to cover about 500 health facilities in 71 (30%) out of 240 districts located in 10 States.

This surveywas planned to measure outcome indicators on quality of care at IMCI health

facilities(1)

Integrated Management of Childhood Illness (IMCI) is a strategy developed by the World

Health Organization (WHO) and United Nations Children's Fund (UNICEF) to improve

child survival in resource poor settings(2)

Infant and child mortality remains high in developing countries, where almost 10 million

deaths occur annually in children under-5 years old (3)

I.M.C.I. Strategy:-

The integrated management of child hood illness (I.M.C.I) strategyover the last decade

childhood mortality decreased by about l5%, however the reduction was not-universal

with poorer countries having static or even increasing childhood deaths. Still over 50

countries are having childhood mortality rates over 100 per 1000 live birth. Of

theestimated11 million deaths of children under 5 years in the developing countries the

majority die during their first year of life. Seven out of 10 deaths are due to preventable

or easily treatable conditions namely: pneumonia, diarrhea, malaria, and measles singly

or in combination usually on a background of malnutrition. Projection based on the

1996, global burden of disease indicates that these conditions will still be major

contributors to child deaths up to the year 2020Unless efforts to control them are

accelerated(4)

(2)

Statement of the Problem:

IMCI is expected to reduce mortality rate in Sudan. In the same time there are some

challenges for implementing IMCI. One of the challenges is inefficient of training nurses.

The major problem identified with IMCI training was a lack of sufficient time during the

course. One reason for this is that, in South Africa and other high HIV prevalence

countries, an HIV component has been added to IMCI without extending the duration of

the course(5)

Objective:-

General objective:

To assess the efficiency of IMCI training program for nurses

Specific objective:

To assess knowledge of nurses in integrated management of child health.

To assess the prevalence of trained nurses in IMCI.

To assess the concepts of nurses regarding IMCI.

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CHAPTER TWO

LITERATURE REVIEW

Integrated Management of Childhood Illness (IMCI)

What is IMCI?

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 counseling of caretakers, and speeds up the referral of

severely ill children. In the home setting, it promotes appropriate care seeking behaviors,

improved nutrition and preventative care, and the correct implementation of prescribed

care

Why is IMCI better than single-condition approaches?

Children brought for medical treatment in the developing world are often suffering from

more than one condition, making a single diagnosis impossible. IMCI is an integrated

strategy, which takes into account the variety of factors that put children at serious risk. It

ensures the combined treatment of the major childhood illnesses, emphasizing prevention

of disease through immunization and improved nutrition.

(4)

How is IMCI implemented?

Introducing and implementing the IMCI strategy in a country is a phased process that

requires a great deal of coordination among existing health programmers and services. It

involves working closely with local governments and ministries of health to plan and

adapt the principles of the approach to local circumstances. The main steps are:

Adopting an integrated approach to child health and development in the national

health policy.

Adapting the standard IMCI clinical guidelines to the country’s needs, available

drugs, policies, and to the local foods and language used by the population.

Upgrading care in local clinics by training health workers in new methods to examine

and treat children, and to effectively counsel parents.

Making upgraded care possible by ensuring that enough of the right low-cost

medicines and simple equipment are available.

Strengthening care in hospitals for those children too sick to be treated in an

outpatient clinic.

Developing support mechanisms within communities for preventing disease, for helping

families to care for sick children, and for getting children to clinics or hospitals when

needed.

IMCI has already been introduced in more than 75 countries around the world.

What has been done to evaluate the IMCI strategy?

MCA has undertaken a Multi-Country Evaluation (MCE) to evaluate the impact, cost and

effectiveness of the IMCI strategy. The results of the MCE support planning and

advocacy for child health interventions by ministries of health in developing countries,

and by national and international partners in development. The MCE was conducted in

Brazil, Bangladesh, Peru, Uganda and the United Republic of Tanzania.

(5)

The results of the MCE indicate that:

IMCI improves health worker performance and their quality of care;

IMCI can reduce under-five mortality and improve nutritional status, if implemented

well;

IMCI is worth the investment, as it costs up to six times less per child correctly

managed than current care;

Child survival programmers require more attention to activities that improve family

and community behavior.

The implementation of child survival interventions needs to be complemented by

activities that strengthen system support;

A significant reduction in under-five mortality will not be attained unless large-scale

intervention coverage is achieved(6)

Implementation of IMCI in Sudan:-

Systematic approach to IMCI implementation at district level: key steps

1. One-day IMCI orientation workshop for staff from State Ministry of Health, local

government, and non-governmental organizations operating in the state.

2. Establishment of an IMCI committee at state level with assignment of an IMCI

coordinator, including the state minister of health, state ministry of health director-

general, EPI coordinator, nutrition coordinator, director of pharmacy, and

representative of state non-governmental organizations.

3. Assessment and preparation of a training center for IMCI training activities.

4. Training of trainers to build state capacity for IMCI training.

5. Selection of locality for IMCI implementation based on the following

considerations:

a. Number, conditions and functionality of health centers in the area;

b. Implementation of other initiatives in the area(e.g., community-based basic

development needs or BDN);

(6)

c. Presence of non-governmental organizations working in the area with a focus on

health;

d. High proportion of children under-5;

e. High prevalence of the main problems targeted by IMCI.

6. Collection of baseline data, with findings discussed in an IMCI orientation workshop.

7. Assessment of health facility basic needs and supplies (e.g. daily register, sick young

infant and child recording forms, monthly reporting forms, IMCI chart booklets and

mother cards, timers to count the respiratory rate, thermometers and scales).

8. IMCI district planning workshop

9. Training in case management (skills acquisition) for doctors and medical assistants.

10. Training in facilitation and follow up skills

11. Follow up after training (skills reinforcement), conducted 6-12 weeks after the IMCI

training course.

12. Supervision, carried out at Federal, state and lower level (routine supervision).

Federal supervision includes review of implementation of the annual plan, visit to the

IMCI training site and drug store, and visit to at least 3 health facilities implementing

IMCI in the state (using the form for follow-up visits after IMCI training, which includes

review of health provider and health facility performance). All health facilities are

supposed to be visited on a quarterly basis. Supervisors undergo a 3-day training on IMCI

supervision, including practicing the use of the IMCI supervisory checklist under the

supervision of the course facilitators. Reports are collated on a quarterly basis and sent to

the central office in Khartoum.

13. Selection of a community for IMCI implementation to introduce the IMCI community

component; training of trainers of volunteers; assignment of a community component

coordinator; KAP survey; training of volunteers.(7)

Sumaia Mohammed Al Fadil – et al start research- Integrated Management of Childhood

Illnesses strategy: compliance with referral and follow-up recommendations in Gezira

State, Sudan .

(7)

CONCLUSION:

In Massalamia a resource-constrained environment in which IMCI

implementation was well received by the community — only about half of children

judged to be in need of urgent referral were taken for that care within 24 hours. Most

children in need of follow-up received their first treatment dose in the health facility.

This aspect of IMCI was commented upon favorably by caretakers, and it may

encourage them to return for follow-up. Rates of return might also improve if return

visits for children currently asked to return after 14 or 30 days were scheduled earlier(8)

Zein A. Karrar MRC.P (UK), FRCP (L), FRCPCH (UK).presented research:

Integrated Management of Childhood Illness (IMCI) �Training in SudanExperience

with In-service Training and the JUSTIFICATION, need and impact of IMCI Pre

service Training.

Zein:conclusion of this research The( introduction of 1.M.C.I. training will improve

care for children in Sudan, sustain the service and have a positive impact on training

ofhealth worker by emphasizing relevance of the curricula& improvingquality of

training through introduction of innovative, objective teaching and assessment tools(9)

Christiane Horwood*1, Anna Voce2, Kerry Vermaak1, Nigel Rollins3,4 andShamim

Qazi4 start research about: Experiences of training and implementation of integrated

management of childhood illness (IMCI) in South Africa: a qualitative evaluation of

the IMCI case management training course

Christiane Conclusion:

The IMCI training course was reported to be an effective method of acquiring skills,

butmore time is required, either during the course, or with follow-up, to improve

IMCI implementationInnovative solutions may be required to ensure that adequate

skills are acquired and maintain. (10).

CR Titaley,1H Jusril,1I Ariawan,1N Soeharno,1T Setiawan,2MW Weber2,3

presented research:

Challenges to the implementation of the integrated management of childhood illness

(IMCI) at community health centresin West Java province, Indonesia

(8)

CR Titarley Conclusion:

Interventions aiming to create local regulations endorsing IMCIimplementation;

promoting monitoring and supervision; encouraging on-the-job training for health

workers; and strengthening training programmers, counseling and other promotional

activities are important for promoting IMCI implementation in West Java province, and

are also likely to be useful elsewhere in the country(11)

DuyenThi Kim Nguyen., Karen K. Leung., Lynn McIntyre William A. Ghali, RegSauve

are presented research about Does Integrated Management of Childhood Illness (IMCI)

Training Improve the Skills of Health Workers? A Systematic Review and Meta-Analysis

DuyenThiKimNguyen are conclusion to: Findings suggest that IMCI training improves

health worker performance. However, these estimates need to beinterpreted cautiously

given the observational nature of the studies and presence ofheterogeneity(12)

(9)

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CHAPTER THREE

METHODOLOGY:

3.1Study design:-

Descriptive cross sectional study conductive during: Aug2014-Feb2015

3.2Study population: -

Nurses in Ribat hospital

3.3Study area:-

The study was conducted in Ribat university hospital which located In Khartoum Burri

3.4Sample technique:

Total coverage

3.5Data collection technique:

1- Interview – nurses – key person

2- Observation

3- Secondary data

3.6Data collection tools:

1- Questionnaire

2- Check list

3- Previous study

3.7Data analysis:

Statistical package for social sciences

3.8 Ethical consideration:

-Verbal consent from hospital

-Verbal consent from nurses

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CHAPTER FOUR

RESULT

Table NO(1) Age of nurses by years

Age of nurses by years Frequency Percent

20-25years 15 30.0

25-30years 25 50.0

30-35years 10 20.0

Total 50 100,0

Most of the studied nurses are in the age group of 25-30y about 50%

Table NO(2): Experience of nurses by years

Experience of nurses by years Frequency Percent

2 - 3years 16 32.0

4- 5years 29 58.0

6- 8years 5 10.0

Total 50 100,0

In this table observe age 4-5y is more common on experience about 58%

(11)

Table No(3) Gender

Gender Frequency Percent

Male 5 10.0

Female 43 86.0

3 1 2.0

Total 49 98.0

Missing system 1 2.0

Total 50 100

In this table see female is most common in study than male about 86%

Table No(4) -Education level

Education level Frequency Percent

BSC 46 92.0

Master 3 6.0

Diploma 1 2.0

Total 50 100,0

In this table observe BScs is most common in study than other about 92%

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TableNo(5)The time period of IMCI study it’s enough

The time period of IMCI study it’s enough Frequency Percent

Yes 13 26.0

NO 29 58.0

My be 8 16.0

Total 50 100.0

In this table see more result the time is not enough about 58%

TableNO (6) the study of IMCI course is useful

The study of IMCI course is useful Frequency Percent

Yes 1 6 32.0

NO 16 32.0

My be 18 36.0

Total 50 100.0

In this table see more result maybe IMCI is useful about 36% and equal result between

yes and no about 32%

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TableNo(7) why the study of IMCI course is not useful

Why the study of IMCI course is not useful Frequency Percent

time of study not enough 15 30.0

there is no Sufficient teacher 1 2.0

not study IMCI 1 2.0

Total 17 34.0

Missing system 33 66.0

Total 50 100

In this table observe more result of IMCI is not useful due to time of study is not

enough about 30% and no sufficient of teacher about 2%

Table No (8) Practical training during the undergraduate study

Practical training during the undergraduate study Frequency Percent

Yes 1 6 32.0

NO 31 62.0

My be 3 6.0

Total 50 100.0

In this table see most result not get IMCI training about 62%

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Table No (9) Cause of missing practical training

Cause of missing practical training Frequency Percent

not study IMCI 1 2.0

there is no opportunity Valid training 21 42.0

there is no training in college 8 16

Total 30 60.0

Missing system 20 40.0

Total 50 100

In this table see result of cause of missing practical training in IMCI du to is no

opportunity to training in hospital about 42%

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Result of interview with key person

1. The objective of introducing of IMCI course is to improve the role of community

in the health of under 5 children and the role of health center regarding child

health .also, the objective of the IMCI to improve the management of child illness

at the level of health centers and hospitals.

2. Training of student experienced failure due to the lack of facilities in which IMCI

is applied, actually IMCI is not applied even by those who trained.

3. The health workers believe that it is not applicable practically and it needs time

and money.

4. The poor monitor and supervision of the program is main factor.

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CHAPTER FIVE

5.1 Discussions:

THE Study IS aiming at assessing the efficiency of IMCI training

program allof the studied nurses are post graduate attended a theoretical

during their undergraduate studies. The practical part is not fulfilled for most

of them (62%)>the age group of nurses is fair 25 – 30.

An ample time for in-services training exists as most of them had a working

period of not more than 5 years. 58%of the nurses had an experience of 4-5y

without any training in IMCI (table no 2).

The theoretical course seems to be short as 58% of the nurses believe.

Result about the efficiency for the course showing dissatisfaction of most of

the nurses (table no 6).

(Table no7) showing the main reasons ofdissatisfaction. The main factor; the

course is short if compared with material and the contents of the

course42%of the nurses did not attend service training as there are no

opportunities.

(17)

5.2 CONCLUSION:

A lot of deficiencies were found in the result of this study regarding the theoretical part,

The course material and content are too much for the limited time of the course

(One week)

There is a deficiency in the practical training, almost most of the nurses (62%)

did not attended

Practical training in IMCI at the levelof community health centers or hospital.

(18)

5.3RECOMMENDATIONS:

Revision of IMCI course objectives and contents.

Enough time should be allocated for IMCI.

Enough time should be allocated for the practical part of the course.

Enough staff of training teacher.

(19)

REFERENCES:-

1- WHO- IMCI health facilities survey- Emro/CAH/013/E/G2013

2- Tulloch J: Integrated approach to child health in developing countries.Lancet PubMed

Abstract | Publisher Full Text 1999, 354(Suppl 2):

3- The state of theworld’schildren 2008: child survival(http://www.unicef.org)

4-WHO- making Differences, world health organization 1999 - www.sudan.org2003

5-Qazi SA, Muhe LM: Integrating HIV management for children into the Integrated

Management of Childhood Illness guidelines.Trans R Soc Trop Med Hyg. 2006,

100(1):10-13.

6-WHO , Maternal and Child Health -topics/IMCI/en-2015 –

7-WHo --implantation-of IMCI in Sudan2014.

8-Sumaia Mohammed Al FadilI, et al,compliance with referral and follow-up

recommendations in Gezira State, Sudan., 2003

9-ZeinA. Karrar -- Integrated Management of Childhood Illness (IMCI) Training 2003-

10-Christiane Horwood, Anna Voce, Kerry Vermaak, et al, Experiences of training and

implementation of (IMCI) in South Africa: www.biomedcentral.comAug2011

11-WHo-April- south East Asia journal of public healthJun 2014.

12-DuyenThi Kim Nguyen.,et al, Does Integrated Management of Childhood Illness

(IMCI)Training Improve the Skills of Health Workers? ASystematic Review and Meta-

Analysis,jun2013

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The National Ribat University

Faculty of Post Graduate

NURSING SCIENCE

Questioner about

Assessment Efficiency of IMCI Training of Nurses in

Ribat Teaching Hospital

Aug. 2014 – Feb. 2015

Age :

20-25 year 25-30 years 30-35 years

Years of Experience:

2-3 years 4-5 years 6-8 years

Gender:

Female male

Academic Qualification:

Diploma Bachelor Master

For your studies of IMCI:

1. Was the time period Enough:

Yes No somewhat

2. Do you take advantage of this decision:

Yes No somewhat

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If not what are the main obstacles?

1. …………………………………………………………………………

……………………………………………………….

2. …………………………………………………………………………

……………………………………………………….

3. …………………………………………………………………………

……………………………………………………….

3 - Have you training IMCI:

Yes No

If not what are the main obstacles?

1. …………………………………………………………………………

……………………………………………………………..

2. …………………………………………………………………………

……………………………………………………………..

3. …………………………………………………………………………

………………………………………………………………

Check list

Interview:

1. What is main objective of introducing IMCI in our health system?

2. What extend do the training programmersuccess?

3. There are some challenges in implementation of IMCIat the level of

health centers and some hospitals what are challenges and what do

you proposed for solutions?