Consistency of Integrated Management of Newborn and Childhood Illness (IMNCI) in Shire Governmental Health Institution in 2017
Gerensea?et?al. BMC Res Notes
Consistency of?Integrated Management of?Newborn and?Childhood Illness (IMNCI) in?Shire Governmental Health Institution in?2017
Hadgu Gerensea 0
Awoke Kebede 0
Zeray Baraki 0
Hagos Berihu 0
Teklay Zeru 0
Eskedar Birhane 0
Dawit G/her 0
Solomun Hintsa 1
Hailay Siyum 1
Gizenesh Kahsay 1
Gebreamlake Gidey 2
Girmay Teklay 0
Gebremeskel Mulatu 0
0 School of Nursing, College of Health Science, Aksum University , Aksum , Ethiopia
1 School of Public Health, College of Health Science, Aksum University , Aksum , Ethiopia
2 Department of Midwifery, College of Health Science, Aksum University , Aksum , Ethiopia
Objective: In an effort to reduce infant mortality and morbidity, the World Health Organization and other technical partners developed the Integrated Management of Newborn and Childhood Illness (IMNCI). This study focuses on assessment of consistency and completeness of integrated management of neonatal and child hood illness in primary health care units. Results: A total of 384 cases were taken from 3562 cases both from young infant registration (under-2 month old) and child registration (2 months-5 year old). Out of 384 cases, 241 (62.8%) cases were correctly classified and 143 (37.2%) were incorrect classifications. Similarly 164 (42.7%) cases were treated correctly where as 220 (57.3%) treated incorrectly. Only 95 (24.7%) cases have given appropriate appointments where as 289 (75.3%) cases were appointed incorrectly. The overall consistency of IMNCI management is poor. Unless continuous follow up of and training was given, children are not treated as expected. More over using electronic method of IMNCI may alleviate the problem.
Consistency; Integrated Management of Newborn and Childhood Illness (IMNCI)
Integrated management of childhood illness (IMCI) is a
globally proven, primarily community based strategy to
improve child survival and is being implemented
worldwide in countries with high burden of child mortality [
In the past two decades childhood survival has shown
significant improvement globally. This is due to the fact
that many low and middle income countries have been
implementing several strategies to improve child survival
by targeting common causes of infant and child
morbidity and mortality [
]. Despite these children fewer than
five still die in large Numbers [
]. Improving quality of
care in child health services will be essential for further
substantial reductions in under-five child mortality [
IMNCI was pioneer into the health systems of over
100 countries that have high under five mortality with
the strategy to change quality of child health care and
decrease under-five mortality [
Strict follow up to direction and algorithms is a
complex activity. It is determined by contextual factors that
may alter the health workers? extrinsic and intrinsic
capability and/or status to follow through these guidelines [
Up till now, researchers are not focusing about adherence
to these approaches in under developed African
countries, despite these countries being among the first that
initiate IMCI into their general health plan of action [
Even though under five and neonatal mortality is
decreased every year through different strategy
primarily by IMNCI still know the reduction is not much
as expected. This may be due to poor adherence and
inconsistent use of IMNCI. So the present study was
undertaken to evaluate the consistency of IMNCI on
assessment, classification, treatment and follow up
and this study will have base for the effective use of the
guideline and shows missed diagnosis and not treated
institution of shire both urban and rural. But the first
sample was selected by simple random sampling (lottery
The study was conducted in Shire town which is located
1084 and 304? km far from the capital city of Ethiopia,
Addis Ababa and the capital city of Tigray, Mekelle,
The study was conducted from February to June in 2017
in shire Endasilasie town, Tigray regional state, north
Institution based cross sectional study design was used
to address the objective from secondary data (IMNCI
All children under 5?years treated in public health
institution using IMNCI guideline in the town.
All sampled children who are under 5? years of age and
treated in the health centers using IMNCI guide line.
Data collection procedures (instrument, personnel, data quality control)
Data were collected by reviewing registration using a
format similar to IMNCI guide line which has five domains:
assessing ill child, classifying for ill child, treating with
medication, counseling care givers and need for referral.
Data quality management
To assure high quality of the data, emphasis was given
in designing data collection instrument and training on
data collectors. Similarly the questioner format was
pretested before the actual data collection period to modify
Consistency of assessment with classification how
many cases are classified based on their assessment
Consistency of classification with treatment how
many cases are treated based on their classification
Correct classification and treatment classification and
treatments that fits based on IMNCI guideline regardless
of heath professionals difference.
Children under 5? years of age treated for neonatal
and childhood illnesses only in the past 1? year will be
Data analysis procedures
The collected data was checked for its completeness,
consistency and accuracy before analysis. Data was analyzed
and interpreted using SPSS version 21.
Sample size determination
The sample size will be calculated using a single
population proportion formula based on the following
n = (Z?/2)2p(1 ? p)(d)2
where n = minimum sample size required for the study,
d = margin of error = 0.05, Z?/2 value of standard
normal distribution (z = 1.96) with confidence interval of
95% and ? is 0.05.P is taking by 50% or any prevalence of
consistency and completeness of IMNCI study
n = (z?/2)2p(1 ? p)(d)2
= (1.96)2 ? 0.5(1 ? 0.5)(0.05)2 = 384
To get the total sample we have used a systematic
sampling technique from IMNCI registration every 10th
interval was taken from the governmental health
Institution review board (IRB) of Aksum University,
college of health science reviews the protocol to insure full
protection of the rights study subjects. Following the
approval by IRB, official letter of co-operation will write
to respected study area. Data will treated confidentially
and identify subject by number only.
Disease profile of?study participants
In all health institution nurses were primary used IMNCI
guideline but in hospitals physicians were also involved.
A total of 384 cases were taken from 3562 cases both
from young infant registration (under-2? month old) and
child registration (2? months?5? year old) 0.184 (47.9)
cases were young infants where as 200 cases were
children aged from 2?months up to 5?years. Of the total 196
(51.04%) were pneumonia cases and 105 cases were
diarrhea. For further see Fig.?1.
Trend of Hypertension Morbidity from
the OPD in Tigray 2011/12-2014/15
Consistency of?IMNCI implementation
Pneumonia cases were 65.7% correctly clarified but 66.7%
were incorrectly appointed or missed. From 40 cases of
children who have fever only 10 (25%) and 7 (17.5%)
children were classified and treated correctly.
Three cases (17.6%) were correctly managed for local
bacterial infection, while 14 (82.7) were incorrectly
classified, and managed for local bacterial infection. For
further see Table?1.
Over all case management of?IMNCI
Out of 384 cases, 241 (62.8%) cases were correctly
classified and 143 (37.2%) were incorrect classifications.
Similarly 164 (42.7%) cases were treated correctly where
as 220 (57.3%) treated incorrectly. Only 95 (24.7%) cases
have given appropriate appointments where as 289
(75.3%) cases were appointed incorrectly. For further see
Many scholars agreed that IMNCI guild line is the best
tool for the accurate management of under 5? years
children. Similarly it can avoid discrepancy among health
institution and health professional but this research
shows there is gap in the health professionals regarding
Consistency of IMNCI Management
the guide line or maybe there is negligence since many
cases are classified and treated incorrect. But still
different study shows IMNCI guide line has great effect on
reduction of less than five mortality with the health
professional inconsistency usage [
The study shows pneumonia is the leading cause of
morbidity in under five children. This finding is similar
with other study [
]. This may be due most children
were classified by the IMCI algorithm based on the
presence or absence of chest indrawing or fast
breathing. One study shows 41% of the non physician health
professionals have made misdiagnosis [
]. This may be
the contributor for the magnitude of pneumonia.
But this finding was different with the study finding
reviewed from 2010 to 2013 in Ethiopia in which
diarrhea was the leading cause of morbidity [
difference is may be related to the difference in qualification
of health profession.
The study finding revealed that the proportion of
IMNCI implementation was 54.2%. This is below
standard level established (68%), by WHO and UNISEF [
This difference may be related with negligence of health
professionals and may be also related to difference in
qualification of health professionals.
Moreover, this study finding is quite higher than that
of the study conducted in China [
]. The difference
may be due to the policy difference in adherence to the
guide line since WHO recommend using IMNCI for
under developed countries like Ethiopia. Moreover, this
study also shows higher implementation from the study
conducted in Kenya which showed that, only 14% in the
]. This difference may be related to the study
period gap and the study area difference in rural and
urban as experienced health professionals are
transferred in urban area and new health professional and
untrained persons are recruited first in the rural area.
But this research finding is similar with the study
conducted in five tertiary care hospitals of Karachi [
This study also contrary from the study conducted in
Benin which showed performance of individual health
workers varied greatly, from 15 to 88% of patients treated
correctly, in accordance with the IMNCI guide lines
]. This discrepancy is mostly due to the difference of
individual on adhering of using IMNCI. Our study also
shows that 62.8% consistency in assessing and classifying
sick child which is better than that of study conducted in
china which shows only 43.8% were correctly classified
Treatment is about 42.7% consistent with
classification, which still lower than other study finding [
much lower than study conducted in Benin which shows
about 63.6% children treated according to IMNCI
]. This may be due lack of training, supportive
supervision. Some authors noted a decline in
performance and adherence rates depending on the time since
the last IMCI (re-) training [
], whereas others could
not confirm these results [
]. Similarly the updated
guide line of 2016 is more different from the past in
classification and some drugs are changed like
cotrimoxazole to amoxicilline for treatment of pneumonia. But this
finding is similar with study conducted in Pakistan which
shows many children are treated incorrectly due to drug
access problem and poor health professional?s knowledge
on IMNCI [
But study conducted in Tanzania shows increase
treatment use based on IMNCI. This difference could be due
to the focus of the policy, intensive training and frequent
supportive supervision [
]. More over this study finding
is comparable with study conducted in India [
Regarding appointment we found only 24.7%
consistency with its classification, which is low level, very low
compared to WHOs 68% recommendation [
study conducted in Brazil (59%) [
]. But it is similar to
study conducted in Bangladesh which says children fully
assessed or correctly treated but there is problem in
advising and follow up [
]. Moreover it is similar with
study in Namibia, Kenya, Tanzania and Uganda which
shows adherence rates to IMNCI is particularly low in
non-hospital settings [
This study also found that, very low birth weight and
neonatal jaundice, which are referral cases are highly
consistent and complete 100% compared to other cases
and much better than Bangladesh case which says none
of the children classified for very low birth weight or
prescribed correct medication at correct dose [
]. This may
be related with few cases in our study.
Despite the importance of IMNCI on reduction of
under five mortality, the adherence rates for
assessment and classification remained low. Most of the
assessments are classified incorrectly. Similarly the
correctly classified children are receiving inappropriate
In the light of these findings, special attention needs
to be directed towards IMNCI training of all health staff,
with particular emphasis on nurses since almost under-5
OPD are covered by nurses and should be consolidated
with periodic re-training. The findings calls for
continuing and increased efforts to improve the standard of child
care within the framework of IMNCI. Moreover, using
electronic method of IMNCI may alleviate the problem.
Since the study was conducted in specific area it should
be repeated at national level to assess the outcome and
long term impact of IMNCI and also to address the
IMNCI: Integrated Management of Newborn and Childhood Illness; WHO:
World Health Organization; LBW: low birth weight; LBI: local bacterial infection.
HG: conceived and designed the study, analyzed the data and wrote the
manuscript. HG, GM, ZB, HB, TZ, GG, HS, GK, SH, AK, involved in data analysis,
drafting of the manuscript and advising the whole research paper. HG DG, EB
and GT also were involved in the interpretation of the data and contributed to
manuscript preparation. DG, EB, GT were also involved in the supervision over
all the research paper. All authors read and approved the final manuscript.
We would like to thank all study participants and data collectors for their
contribution in success of our work.
This manuscript maintains no competing financial interests declaration from
any person or organization, or non-financial competing interests such as
political, personal, religious, ideological, academic, intellectual, commercial or
Availability of data and materials
The data sets used and analyzed during the current study available from the
corresponding author on reasonable request.
Consent to publish
Ethics approval and consent to participate
Ethical clearance was secured from the Aksum University, College of Health
Science Institution Review Board (IRB) with IRB Number 12/02/2016. Since the
data is from registration permission from Tigray Regional health bureau (TRHB)
and woreda were taken. Furthermore, written consent was taken from TRHB
officer. Moreover, information was recorded anonymously and confidentially.
There is no funding for this research. All cost of data collection and analysis
were covered by the authors.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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