Indian J Pediatr DOI 10.1007/s12098-012-0835-4
ORIGINAL ARTICLE
Integrated Management of Neonatal and Childhood Illness (IMNCI): Skill Assessment of Health and Integrated Child Development Scheme (ICDS) Workers to Classify Sick Under-five Children Hemant D. Shewade & Arun K. Aggarwal & Bhavneet Bharti Received: 22 March 2012 / Accepted: 15 June 2012 # Dr. K C Chaudhuri Foundation 2012
Abstract Objective To assess the skills (diagnostic/counseling) of Integrated Management of Neonatal and Childhood Illness (IMNCI) trained workers; and to assess the degree of agreement between the physician and the IMNCI trained workers of Raipurrani block, district Panchkula, India, to classify sick under-five children in field. Methods The cross-sectional study was conducted in Raipurrani in the outpatient departments of the community health centre and one primary health centre in 2010. Workers from health department and Integrated Child Development Scheme (ICDS) were assessed in this study. They received IMNCI training in 2006, with 1 day refresher training in 2009. Investigator noted his observations using a skill assessment checklist. Under-five child observations were the unit of study. Results Sixteen IMNCI trained workers made 128 child observations. Considering color-coded categorization under IMNCI, agreement with investigator (Kappa) was intermediate; red and yellow categorizations had poor agreement. Morbidity-wise agreement (Kappa) was poor for possible serious bacterial infection, feeding problem, respiratory problem and anemia. Considering final diagnosis, investigator and H. D. Shewade : A. K. Aggarwal School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India B. Bharti Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India H. D. Shewade (*) Department of Community Medicine, Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry, India e-mail:
[email protected]
IMNCI trained worker completely agreed in 45 % child observations. All symptoms were asked only in 15 %. Skills were poor overall for young infants. For children between 2 mo to 5 y, danger signs, neck stiffness, edema, wasting and pallor were checked in /0 0.9 with an IMNCI master trainer. Under-five children attending the OPD for symptoms of any illness were included in the study, on first come first serve basis. Under-five children attending for follow up, immunization, or well baby visits and very sick children requiring resuscitative measures were excluded from the study. The child, after being examined by the investigator was presented to the ANM/AWW. This being a field assessment (not classroom assessment), the investigator did not insist on the use of IMNCI case assessment form. Observations were entered by investigator in case record form, checklist of diagnostic skills and checklist of counseling
skills. These are standard checklists recommended by WHO/UNICEF and Govt. of India for use in the national programme. However, a pre-testing was conducted to standardize the operational aspects of the skill assessment. The child was then sent to the medical officer for routine OPD care. The diagnostic checklist had items/subgroups/morbidities which represented a diagnosis. Each item had component(s) under them. Final color-coded categorization for each under-five child observation was based upon the most severe color-coded categorization for individual morbidities. At the end of completion of eight child observations, supportive supervision was done based on the observations made by the investigator. Data analysis was done using SPSS version 17 computer software. Unweighted kappa statistics was calculated using an online software [4]. Kappa (K) < 0.4 was taken as poor agreement; 0.4 – 0.75 (including extremes) as intermediate, > 0.75 as good; and > 0.9 as excellent agreement [5]. The same quality cut-offs were used for other indicators. For ease of analysis of color-coded categorization, under-five children with no diagnosis/normal children were put into green category. Approval of the Institute Ethics Committee, PGIMER and Haryana State Health Services was taken before conducting the study.
Results Of the 128 child observations, 26 (20.3 %) were young infants (
