|Year : 2022 | Volume
| Issue : 3 | Page : 244-250
Adherence and Implementation-related Challenges of Integrated Management of Childhood Illness Guidelines among Nurses at Health Centers in Port Harcourt, Nigeria
Damiete M Amachree1, Chinemerem Eleke2
1 Department of Midwifery and Child Health, Africa Centre of Excellence in Public Health and Toxicology, Port Harcourt, Nigeria
2 Department of Nursing, Faculty of Clinical Sciences, University of Port Harcourt, Port Harcourt, Nigeria
|Date of Submission||18-Aug-2021|
|Date of Decision||01-Mar-2022|
|Date of Acceptance||14-Mar-2022|
|Date of Web Publication||2-Jun-2022|
Department of Nursing, Faculty of Clinical Sciences, University of Port Harcourt, Port Harcourt
Source of Support: None, Conflict of Interest: None
Background: The Integrated Management of Childhood Illness (IMCI) guidelines are a standardized diagnostic and treatment approach developed by the World Health Organization for the management of common childhood diseases. Objective: This study assessed the adherence and implementation-related challenges of the IMCI guidelines among nurses at health centers in Port Harcourt, Nigeria. Materials and Methods: A cross-sectional descriptive-analytical design was employed to examine nurses in all the 12 Model Comprehensive Primary Healthcare Centers (MCPHCs) in Port Harcourt, Nigeria. The census sampling technique was used to enroll 52 consenting participants. Data were collected by (1) observation and recording on a checklist and then (2) semi-structured questionnaire. Collected data were analyzed using frequency, percentages, Chi-square, and prevalence ratio at a 5% level of significance with the aid of IBM-SPSS version 25. Results: About half (53.8%) of the participants demonstrated adequate overall adherence to all the steps of the IMCI guidelines. Adequate adherence to all the steps of the IMCI guidelines was 83% higher among participants trained on the IMCI guidelines (P = 0.038). The participants’ educational qualifications (P = 0.722) and years of professional nursing practice (P = 0.477) were not associated with adherence to the IMCI guidelines. The categories of the IMCI guidelines implementation-related challenges reported by the participants were a lack of training update on the IMCI guidelines (94.2%), a lack of the IMCI booklets (69.2%), and work-time pressure (53.8%) among others. Conclusion: Adherence to the IMCI guidelines was short of desired levels. In recommendation, frequent training and regular provision of the IMCI booklets in the MCPHCs are required.
Keywords: Child, guideline adherence, Nigeria, primary health care, professional practice
|How to cite this article:|
Amachree DM, Eleke C. Adherence and Implementation-related Challenges of Integrated Management of Childhood Illness Guidelines among Nurses at Health Centers in Port Harcourt, Nigeria. Int J Med Health Dev 2022;27:244-50
|How to cite this URL:|
Amachree DM, Eleke C. Adherence and Implementation-related Challenges of Integrated Management of Childhood Illness Guidelines among Nurses at Health Centers in Port Harcourt, Nigeria. Int J Med Health Dev [serial online] 2022 [cited 2022 Aug 12];27:244-50. Available from: https://www.ijmhdev.com/text.asp?2022/27/3/244/346432
| Introduction|| |
Child mortality is a global issue that affects about 10 million children under 5 years of age in low- and middle-income countries. Malaria, pneumonia, diarrhea, measles, malnutrition, and HIV/AIDS are among the leading causes of this high mortality rate. The World Health Organization (WHO) adopted the Integrated Management of Childhood Illness (IMCI) strategy as a means toward reducing the global child mortality rate by two-thirds.
The WHO developed IMCI in 1992 as a case-management method for common childhood diseases. It is a standardized diagnostic approach designed for nonphysician professionals working in resource-limited settings, such as nurses and midwives. The IMCI guidelines are structured as a set of basic questions in a step-by-step algorithm. The steps include assessing the condition, classifying the condition, identifying the required treatment, treating the condition, counseling, and follow-up. The algorithm was designed to assist nurses and midwives in classifying diseases based on their presentation, severity, and danger indicators. When followed correctly, these IMCI principles have been demonstrated to enhance care quality while also lowering treatment costs. Since its beginning, the IMCI program has had two fundamental goals. They include improving nurses’ and midwives’ ability to manage childhood diseases and improving mothers’ ability to identify danger signs. Consequently, the IMCI strategy gears toward reducing the impact of the major childhood illnesses on child mortality and morbidity. It offers a comprehensive health program that focuses on the developmental needs of children under 5 years of age. The program emphasizes six main areas of childcare. They include adequate nutrition, disease prevention, vaccination/immunization, wellness promotion and counseling for mothers, and referral services.
Nigeria fully adopted the IMCI program in 1996. Despite the nationwide launch of the IMCI program, in Nigeria, some 25 years ago, the under-5 mortality rate has risen from 128 deaths per 1000 live births in 2013 to 132 deaths per 1000 live births in 2018. It implies that about one in eight children died before their fifth birthday, which is far higher than one in 95 children dying before their fifth birthday in Europe (11 per 1000 live births). As Nigeria moves closer to achieving the sustainable development goals and universal health coverage, frequent monitoring of nurses’ adherence to the IMCI approach will be critical to the success of the intervention program. Furthermore, it may be vital to gain insight into nurses’ perspectives on the program’s implementation-related challenges. Such insights can inform the development of critical policy recommendations that could help improve the effectiveness of the IMCI program.
In Port Harcourt (southern Nigeria), the under-5 mortality rate is 79 deaths per 1000 live births. It suggests that about one in 13 children died before their fifth birthday. The high prevalence may connote ineffectiveness in IMCI implementation in the region. Previous research from outside Nigeria has found many obstacles that hinder nurses from properly following the IMCI guidelines. They include the poor definition of parts of a service package for children, fragmented mentorship, limited access to essential IMCI booklets, and vertical control of supplemental programs included in the IMCI guidelines, such as vaccination. More so, no recent study in Port Harcourt has documented the IMCI adherence and implementation-related challenges within the past 10 years.
Based on anecdotal reports and observations from the researchers’ experiences as clinical preceptors in Port Harcourt, nurses at two basic healthcare facilities appeared to diagnose rather than categorize children using the IMCI criteria presented in the IMCI child booklet. There was no IMCI child booklet available at one additional primary healthcare center. Consequently, inappropriate treatments may be prescribed while life-saving actions are omitted. It has thus become crucial to examine adherence to the IMCI guidelines and explore the IMCI implementation-related frustrations. This study examined the adherence to the IMCI guidelines and explored the frustrations that hinder the IMCI implementation among nurses in primary healthcare institutions in Port Harcourt, Nigeria. This study examined the adherence and implementation-related challenges of the IMCI program among nurses in primary healthcare centers in Port Harcourt, Nigeria. The specific objectives of this study were to (1) assess the IMCI guidelines adherence, (2) examine the influence of educational qualification, the years of professional experience, and training on the IMCI guidelines adherence, and (3) identify the IMCI guidelines implementation-related challenges.
| Materials and Methods|| |
This study followed the Helsinki Declaration guidelines for studies involving humans. It was given ethical approval by the University of Port Harcourt’s Research Ethics Committee on January 10, 2020 (approval ID: UPH/CEREMAD/REC/MM69/011). Participation in this study was communicated to be voluntary. Before data collection, each participant provided written informed consent.
A cross-sectional descriptive-analytical design was employed in this study among consenting nurses in the primary health centers in Port Harcourt. This study was carried out in all the 12 Model Comprehensive Primary Healthcare Centers (MCPHCs) within Port Harcourt Local Government Area (LGA) in Rivers State. They include the health centers at Abuloma, Amadi-Ama, Azuabie, Bundu-Ama, Churchill, Elekahia, Mgbundukwu, Nkpolu, Okuru, Orogbum, Ozuboko, and Potts-Johnson in Port Harcourt LGA. Port Harcourt LGA is situated about 52 kilometers southeast of Ahoada and 40 kilometers northwest of Bori. It shares boundaries with Obio-Akpor on the north, Eleme on the east, Okirika on the south, and Degema on the west. It accommodates at least 650,000 persons within its 109 square kilometers area.
All the nurses practicing in the 12 MCPHCs in Port Harcourt LGA composed the population for this study, which amounted to 63. The census sampling method was used to enroll all members of the population into the study, but only 52 nurses consented to participate in this study (82.5% of the population). The instrument used in collecting data from the participants comprised a checklist and a validated questionnaire consisting of two sections (A and B). The checklist was composed of items focusing on adherence to the IMCI steps of assessment, classification, identification, treatment, and counseling. The validated questionnaire had Section A that included items related to the socio-demographic characteristics of the participants. Section B comprised open-ended questionnaire items relating to the IMCI guidelines implementation challenges.
The data collection procedure began with observing what each of the participants did when attending to a patient (child below the age of 5 years) and ticking off accomplished IMCI steps on a procedure checklist designed for this study. After all nurses in each of the health centers had attended to their patients, the questionnaire was given to them to fill anonymously. The entire period of data collection lasted 3 months (from February to April 2020).
Frequency and percentage were employed as descriptive statistical techniques. The frequency and percentages were used to summarize the checklist and questionnaire items. To test the relationship between socio-demographic variables and adherence to the IMCI recommendations, Chi-square, Fisher exact test, and prevalence ratio statistics were employed. Statistical significance was set at a 5% significance level. The data were analyzed with the aid of Statistical Products and Service Solutions version 25 (IBM-SPSS, Chicago, IL, USA).
| Results|| |
A total of 52 nurses were observed. The predominant age category among the participants was 30–39 years (40.4%). Most of the participants were females (82.7%), and they were married (82.7%). The majority of them had a post-basic nursing diploma (53.8%). More than half of them had practiced professional nursing for 1–10 years, and few (15.4%) were formally trained on the IMCI guidelines. The background socio-demographic characteristics of the participants are summarized in [Table 1].
Adequate overall adherence to all the steps of the IMCI guidelines was demonstrated by about half of the participants (53.8%). Adherence with the individual IMCI steps is summarized in [Table 2].
Overall adherence to all steps of the IMCI guidelines was significantly associated with training on the IMCI guidelines (P = 0.038). The participants who had attended training updates on IMCI were 83% more likely to adhere to all the steps of the IMCI guidelines. There was however no significant association between adherence to all the steps of the IMCI guidelines and variables such as educational qualification (P = 0.722) and years of professional nursing practice (P = 0.477). The association between adherence to the IMCI guidelines and socio-demographic variables is summarized in [Table 3].
|Table 3: Association between socio-demographic variables and adherence to IMCI guidelines (n = 52)|
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Five categories of the IMCI guidelines implementation-related challenges were reported by the participants as summarized in [Table 4]. They include a lack of training updates on the IMCI guidelines (94.2%), a lack of the IMCI booklets and relevant resources (69.2%), and work-time pressure (53.8%) among others.
| Discussion|| |
Nurses are one of the largest groups of healthcare workers that offer direct nursing services to mother–child dyads in the primary care setting. Thus, their ability to adhere strictly to the IMCI guidelines could make a difference in the quality of healthcare received by children under the age of 5 years for the common childhood diseases. This study revealed that about one in every two of the participants adhered completely to all steps of the IMCI guidelines. This result is disturbing in that if around half of the participants applied the IMCI guidelines, it would suggest that some children do not get the expected quality of care. Considering that the nursing and midwifery training covers classroom topics such as introduction to IMCI, one would expect all the participants to be proficient in IMCI guidelines applications. The participants seemed inclined toward diagnosing clients based on general nursing problem-solving principles for the client management rather than the IMCI guidelines. This finding is higher than that reported in a South-Sudanese study, which found that one in every 10 (9.9%) of the healthcare workers adhered to all the steps of the IMCI guidelines during client/patient care. The discrepancy in findings could be linked to the dissimilarity in the sampling method utilized for the study. The South-Sudanese study examined 232 participants purposively selected from 36 health centers, whereas this study assessed 52 participants drawn from 12 model health centers by census technique. Based upon the context that purposive is a nonprobability sampling method, it may have grossly underestimated the true level of adherence to IMCI. The finding of this study, based on a census sample, is perhaps a better estimate for the level of adherence to the IMCI guidelines. More so, this finding is also higher than those reported in national studies from Namibia (11%), Kenya (11%), Tanzania (14%), and Uganda (20%). Since the quality of primary healthcare for children under 5 years relies partly on nurses’ effort, this finding is even more disheartening. The reason for this result may not be far from the conclusion of a Philippines study that noted low motivation to implement the IMCI guidelines among health workers. It may be possible that personal and systemic challenges abound, which hinder the sustained adherence to the IMCI guidelines.
This study demonstrated that participants’ adherence to the IMCI guidelines was determined by attending training updates on the IMCI guidelines. This study further revealed that IMCI training updates increased the likelihood of adherence to all steps of the IMCI guidelines by 83%. This result is not surprising, as the update of clinical knowledge is essential to reliable nursing services. This study showed that only one in every six (15.4%) of the participants were acquired training updates on the IMCI guidelines. The limited engagement of nurses in regular IMCI updates may have resulted in poor adherence as implied by this study’s finding. Inadequate funding of the healthcare industry in developing countries such as Nigeria may be a general challenge that impacts the funding of regular or frequent training updates on the IMCI guidelines, which would have enhanced the quality of the IMCI services. This finding corroborates with an Ethiopian study that reported that training updates on IMCI increased the likelihood of adherence to the IMCI guidelines by 2.7 times. The concord in findings would suggest that more investment into supporting regular IMCI training updates is required for nurses in the primary healthcare sector. Nonetheless, this study demonstrated that the years of professional nursing experience and educational qualifications had no significant impact on adherence to the IMCI guidelines. This finding was unexpected, considering the assertion that clinical knowledge is more in-depth at higher levels of academic training and qualification. The assertion implies that the knowledge horizon of a university degree holder is expected to be unmatched by that of nondegree holders. Nevertheless, the assertion contradicts the observation in Tanzania that found low adherence to the IMCI guidelines among clinicians with higher educational qualifications and no association between adherence to the IMCI guidelines and educational qualifications. This finding did not support the results of the South-Sudanese study, which reported that adherence to the IMCI guidelines was associated with educational qualification (P = 0.005). This contrast in findings could be linked to the dissimilarities in the proportion of IMCI-trained participants in the study. The South-Sudanese study examined a sample with a higher proportion of trained participants (about one in every five, 22.8%) compared with this present study (about one in every six, 15.4%). More systematic reviews and controlled trials may be needed to adequately establish whether a clear-cut association truly exists between educational qualification and adherence to the IMCI guidelines.
This study highlighted that the IMCI implementation-related challenges were found to include a lack of training updates on the IMCI guidelines, a lack of IMCI booklets and resources, work-time pressure, the poor supervisory role of policy administrators, and the behavior of uncooperative clients/patients. These challenges emanate mainly from the healthcare system. This study highlighted that the IMCI implementation-related challenges were found to include a lack of training updates on the IMCI guidelines, a lack of IMCI booklets and resources, work-time pressure, the poor supervisory role of policy administrators, and the behavior of uncooperative clients/patients. These are considered to be personal and organizational challenges within the healthcare system. The finding that the participants were not engaged in regular training updates on the IMCI guidelines agrees with the findings of two South African studies., The two studies reported that nurses were not frequently engaged in IMCI training updates. Such situations hold implications for the healthcare system as it is possible for the nurses to come across a new IMCI booklet in the facility without even knowing that there was a new chart booklet that should use alongside. This finding is disturbing in the light of the pivotal role that nurses and midwives are expected to play in IMCI implementation. Furthermore, a shortage of material resources will make IMCI implementation difficult to achieve. One may argue that there is no point in assessing a child when the required medication is out of stock. This has a negative impact on the community as it could result in the community’s loss of confidence in the healthcare system as they do not receive the needed IMCI services. Work-time pressure cannot be overemphasized was identified as a challenge in a Tanzanian study. Nurses who work in a 24-hour healthcare center may end up working overtime because of their increased workload, and this can inhibit the proper implementation of IMCI. It is possible that at certain times, nurses do not really avoid implementing IMCI but skip IMCI steps in a bid to haste workflow to reduce waiting time for patients in the queue. This tends to negatively affect the quality of care in the long run. Additionally, nurses sometimes deal with difficult clients at certain times. Noncooperative patients could become a challenging barrier to IMCI implementation. This is true given that mothers may insist on having prescription medication even when it is not recommended by the IMCI strategy. Some patients may insist that the nurse should attend to them first even when it is not their turn in the consulting room. Depending on the average time needed to complete steps of the IMCI guidelines, some patients when queuing may accuse professional nurses of being too slow. All these examples could motivate a nurse to skip some IMCI steps.
Addressing the highlighted IMCI implementation-related challenges will equip nurses in the MCPHCs with the required skill and impetus to adhere to the IMCI guidelines. It perhaps rests within the court of administrators to lobby policy-making windows toward improving the identified situation.
The major limitation of this study is that it utilized only the MCPHCs in Port Harcourt; hence the findings cannot be used for the generalization outside the study population.
| Conclusion|| |
Nurses in MPHCs in Port Harcourt had inadequate adherence to the IMCI guidelines. Systemic factors such as a lack of training updates and limited resources were implicated. Training updates and the provision of resources may be essential to optimally support and ultimately enhance the quality of the IMCI program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Criteria for authorship
All the authors took part in designing and revising the article.
This article was read and approved for publication by all the authors.
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[Table 1], [Table 2], [Table 3], [Table 4]