Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi

Background Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi. Methods Data were obtained from the 2013–2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity. Results 3136 clinical visits for children 2–59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity. Conclusions Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.

[1]  D. Robinson The integrated management of childhood illness. , 1996, Africa health.

[2]  S. Aston The role of rapid diagnostic tests in managing adults with pneumonia in low-resource settings , 2014, Pneumonia.

[3]  S. Cousens,et al.  Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt , 2013, BMJ Open.

[4]  M. Kruk,et al.  Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania , 2017, Bulletin of the World Health Organization.

[5]  V. Cubaka,et al.  A systematic review of supportive supervision as a strategy to improve primary healthcare services in Sub‐Saharan Africa , 2016, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.

[6]  M. Deming,et al.  Predictors of health worker performance after Integrated Management of Childhood Illness training in Benin: a cohort study , 2015, BMC Health Services Research.

[7]  S. Owusu-Agyei,et al.  An Evaluation of the Clinical Assessments of Under-Five Febrile Children Presenting to Primary Health Facilities in Rural Ghana , 2011, PloS one.

[8]  M. Laurant,et al.  Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world? , 2015, International journal of nursing studies.

[9]  Gregory S Kabadi,et al.  Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania , 2004, The Lancet.

[10]  Cameron Bowie,et al.  Retention of health workers in Malawi: perspectives of health workers and district management , 2009, Human resources for health.

[11]  Gaetano Borriello,et al.  mPneumonia, an Innovation for Diagnosing and Treating Childhood Pneumonia in Low-Resource Settings: A Feasibility, Usability and Acceptability Study in Ghana , 2016, PloS one.

[12]  L. Muhe,et al.  Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review. , 2012, Health policy and planning.

[13]  Emon Kalyan Chowdhury,et al.  Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study , 2004, The Lancet.

[14]  S. Qazi,et al.  Early identification and treatment of pneumonia: a call to action , 2015, The Lancet. Global health.

[15]  G. Burnham,et al.  Improving facility-based care for sick children in Uganda: training is not enough. , 2005, Health policy and planning.

[16]  Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census , 2016, Malaria Journal.

[17]  B. Genton,et al.  Clinical features for diagnosis of pneumonia in children younger than 5 years: a systematic review and meta-analysis. , 2015, The Lancet. Infectious diseases.

[18]  M. English,et al.  Oxygen and pulse oximetry in childhood pneumonia: a survey of healthcare providers in resource-limited settings. , 2012, Journal of tropical pediatrics.

[19]  S. Anyangwe,et al.  Inequities in the Global Health Workforce: The Greatest Impediment to Health in Sub-Saharan Africa , 2007, International journal of environmental research and public health.

[20]  S. Suh,et al.  Improving quality of reproductive health care in Senegal through formative supervision: results from four districts , 2007, Human resources for health.

[21]  A. Amouzou,et al.  Determinants of Integrated Management of Childhood Illness (IMCI) non–severe pneumonia classification and care in Malawi health facilities: Analysis of a national facility census , 2017, Journal of global health.

[22]  R. Scherpbier,et al.  Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania. , 2006, Bulletin of the World Health Organization.

[23]  Heather J Zar,et al.  Incidence and severity of childhood pneumonia in the first year of life in a South African birth cohort: the Drakenstein Child Health Study. , 2015, The Lancet. Global health.

[24]  N. Rollins,et al.  An Evaluation of the Quality of IMCI Assessments among IMCI Trained Health Workers in South Africa , 2009, PloS one.

[25]  R. Scherpbier,et al.  Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness. , 2005, Health policy and planning.

[26]  R. Sauve,et al.  Does Integrated Management of Childhood Illness (IMCI) Training Improve the Skills of Health Workers? A Systematic Review and Meta-Analysis , 2013, PloS one.

[27]  J. Bryce,et al.  Quality of sick child care delivered by Health Surveillance Assistants in Malawi , 2012, Health policy and planning.

[28]  E. McAuliffe,et al.  What makes staff consider leaving the health service in Malawi? , 2014, Human Resources for Health.

[29]  S. Shepperd,et al.  Does pulse oximeter use impact health outcomes? A systematic review , 2015, Archives of Disease in Childhood.

[30]  C. Lengeler,et al.  Embedding systematic quality assessments in supportive supervision at primary healthcare level: application of an electronic Tool to Improve Quality of Healthcare in Tanzania , 2016, BMC Health Services Research.

[31]  D. Hamer,et al.  Clinical management of children with fever: a cross-sectional study of quality of care in rural Zambia , 2017, Bulletin of the World Health Organization.

[32]  Don de Savigny,et al.  The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania. , 2004, Health policy and planning.

[33]  C. Emdin,et al.  Utility and feasibility of integrating pulse oximetry into the routine assessment of young infants at primary care clinics in Karachi, Pakistan: a cross-sectional study , 2015, BMC Pediatrics.

[34]  G. Zou,et al.  A modified poisson regression approach to prospective studies with binary data. , 2004, American journal of epidemiology.

[35]  S. Gove,et al.  Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. , 1997, Bulletin of the World Health Organization.

[36]  Valéry Ridde,et al.  The community case management of pneumonia in Africa: a review of the evidence. , 2015, Health policy and planning.

[37]  M. Deming,et al.  The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin. , 2010, Health policy and planning.

[38]  Gaetano Borriello,et al.  mPneumonia: Development of an Innovative mHealth Application for Diagnosing and Treating Childhood Pneumonia and Other Childhood Illnesses in Low-Resource Settings , 2015, PloS one.

[39]  J. Bryce,et al.  Quality of care for under-fives in first-level health facilities in one district of Bangladesh. , 2005, Bulletin of the World Health Organization.

[40]  T. Colbourn,et al.  Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi , 2016, Bulletin of the World Health Organization.

[41]  J. Mukherjee,et al.  Nurse mentorship to improve the quality of health care delivery in rural Rwanda. , 2013, Nursing outlook.

[42]  Deborah Havens,et al.  Implementation of World Health Organization Integrated Management of Childhood Illnesses (IMCI) Guidelines for the Assessment of Pneumonia in the Under 5s in Rural Malawi , 2016, PloS one.

[43]  M. Mohanan,et al.  The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India. , 2015, JAMA pediatrics.

[44]  S. Agha The impact of a quality-improvement package on reproductive health services delivered by private providers in Uganda. , 2010, Studies in family planning.

[45]  J. Bryce,et al.  Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil. , 2004, Cadernos de saude publica.

[46]  A. Costello,et al.  Towards a grand convergence for child survival and health: A strategic review of options for the future building on lessons learnt from IMNCI. , 2016 .

[47]  J. Bradley,et al.  Improving the quality of child health services: participatory action by providers. , 2005, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[48]  Elizabeth Hazel,et al.  Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival , 2016, The Lancet.

[49]  L. Hirschhorn,et al.  Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda , 2014, Archives of Disease in Childhood.

[50]  Robert E Black,et al.  Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania. , 2005, Health policy and planning.

[51]  T. Colbourn,et al.  Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study. , 2016, The Lancet. Global health.

[52]  M. Kruk,et al.  Training And Supervision Did Not Meaningfully Improve Quality Of Care For Pregnant Women Or Sick Children In Sub-Saharan Africa. , 2016, Health affairs.

[53]  M. Hosseinipour,et al.  Determining the quality of IMCI pneumonia care in Malawian children , 2014, Paediatrics and international child health.

[54]  B. Daelmans,et al.  Scaling Up Integrated Community Case Management of Childhood Illness: Update from Malawi , 2012, The American journal of tropical medicine and hygiene.

[55]  Cesar G Victora,et al.  How can we achieve and maintain high-quality performance of health workers in low-resource settings? , 2005, The Lancet.

[56]  P. Garner,et al.  Managerial supervision to improve primary health care in low- and middle-income countries. , 2011, The Cochrane database of systematic reviews.

[57]  Jean-Pierre Habicht,et al.  Improving antimicrobial use among health workers in first-level facilities: results from the multi-country evaluation of the Integrated Management of Childhood Illness strategy. , 2004, Bulletin of the World Health Organization.

[58]  Marc Mitchell,et al.  National implementation of Integrated Management of Childhood Illness (IMCI): policy constraints and strategies. , 2010, Health policy.

[59]  Ottar Mæstad,et al.  Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)? , 2014, Social science & medicine.

[60]  Brent D. Fulton,et al.  Health workforce skill mix and task shifting in low income countries: a review of recent evidence , 2011, Human resources for health.

[61]  A. Rowe,et al.  Effect of the Integrated Management of Childhood Illness strategy on health care quality in Morocco. , 2006, International journal for quality in health care : journal of the International Society for Quality in Health Care.