Under-five mortality and morbidity could be reduced through increased implementation of the Integrated Management of Childhood Illness (IMCI) strategy. The aim of the study was to determine challenges facing IMCI-trained professional nurses on implementing this strategy when managing children less than 5 years of age.
A quantitative descriptive survey method was used. The target populations were IMCI-trained professional nurses with the sample of 208 respondents. Data were collected through self-report questionnaires and analysed using statistical analysis system software.
The implementation of the IMCI strategy by IMCI-trained professional nurses in Vhembe primary health care (PHC) clinics continues to face challenges, making it difficult for professional nurses to follow guidelines. These challenges range from staff barriers, management barriers, poor management process and poor infrastructure. All these challenges lead to poor-quality under-five patient care.
Regardless of the IMCI strategy being implemented since its inception in 1999, the under-five mortality remains not reduced. This is related to the identified challenges facing the IMCI-trained professional nurses implementing the strategy.
Every year in low-income countries, more than 10.2 million children die before they reach their fifth birthday, most of them in their first year of life.
In 2018, the World Health Organization (WHO) reported that pneumonia, diarrhoea and malaria were among the highest common causes of under-five child mortality. Nutrition-related factors were also alarming as causing 45% of death to the under-five in sub-Saharan countries. These are priority illnesses that are addressed by the WHO’s Integrated Management of Childhood Illness (IMCI) strategy and the United Nations Children’s Fund (UNICEF).
Even diseases such as malaria would not be easily missed as all under-five children who present with fever are screened and tested for it. In IMCI management, there are six steps, namely: Step 1: Assessment; Step 2: Classify; Step 3: Identify treatment; Step 4: Treat; Step 5: Counsel and Step 6: Follow-up.
In Botswana, the IMCI strategy implementation led to the decrease in under-five child mortality from 90/1000 in 2000 to 48/1000 in 2010.
After 13 years, the implementation of the IMCI strategy was reported to be poor, not only in South Africa but also globally.
There is sufficient evidence of good quality care outcomes from IMCI strategy, and it is therefore of vital importance to focus on what could be performed to optimise the implementation of this strategy.
A quantitative descriptive survey was used for this study. The data were collected from January to March 2017. The population was composed of IMCI-trained professional nurses who were working in the PHC clinics of Vhembe district. Vhembe district is the northern largest most rural part of Limpopo Province which shares its borders with Zimbabwe. The sample calculator was used to determine the number of respondents to participate in this study. Systematic random sampling was performed in 52 PHC clinics, and an additional 20 PHC clinics were conveniently sampled after encountering floods challenges. However, all the respondents met the inclusion criteria. A total of 208 respondents were enrolled. Data were collected through self-administered questionnaires which the respondents completed at their work stations. The questionnaire had the following sections: demographic as well as professional data; challenges facing IMCI-trained professional nurses in implementing the IMCI strategy; perceived challenges of IMCI-trained professional nurses on IMCI strategy implementation; and recommendations for improving IMCI strategy implementation. Data were analysed using statistical analysis system (SAS) (SAS Institute Inc., Carey, North Carolina, United States). Experts in child health and a qualified statistician were consulted during the research planning and data analysis phases. The questionnaire was modified from a study conducted in Botswana
Two-hundred and eight respondents participated in this study. The minimum age for respondents was 24 years, and the maximum age was 63 years. The majority of the study respondents were women (90.4%).
All professional nurses were IMCI-trained but differed with other skills, for example, midwifery (72%), psychiatric (38%), general nursing (only 54%) and community nursing (52%). Sixty per cent of the respondents had a Health Assessment Treatment and Care (PHC) Diploma.
A majority of the respondents (51%) were trained in IMCI between 2006 and 2012. Many of the respondents (37%) have been managing under-five children for more than 10 years. More than half of all the respondents (73%) responded that they had never been followed up post-IMCI training, as shown in
Demographic profiles of respondents (
Variable | Number | % |
---|---|---|
Female | 188 | 90 |
Male | 20 | 10 |
Degree in nursing | 84 | 41 |
Diploma in nursing | 111 | 53 |
Degree and diploma in nursing | 13 | 6 |
3–5 years | 29 | 14 |
5–10 years | 107 | 51 |
Above 10 years | 72 | 35 |
Number | 208 | 100 |
Mean age | 46.4 | Standard dev ± 8.6 |
Min or Max | 24/63 | - |
IMCI, Integrated Management of Childhood Illness; Min, minimum; Max, maximum.
Challenges facing Integrated Management of Childhood Illness–trained professional nurses implementing the Integrated Management of Childhood Illness strategy.
Statement | Frequency ( |
% |
---|---|---|
Agree | 202 | 97 |
Disagree | 5 | 2 |
Neutral | 1 | 1 |
Agree | 140 | 67 |
Disagree | 46 | 22 |
Neutral | 22 | 11 |
Agree | 115 | 55 |
Disagree | 67 | 32 |
Neutral | 26 | 13 |
Agree | 139 | 67 |
Disagree | 50 | 24 |
Neutral | 19 | 9 |
Agree | 90 | 43 |
Disagree | 103 | 50 |
Neutral | 15 | 7 |
Agree | 101 | 49 |
Disagree | 63 | 30 |
Neutral | 44 | 21 |
Agree | 69 | 33 |
Disagree | 117 | 56 |
Neutral | 22 | 11 |
Agree | 61 | 29 |
Disagree | 112 | 54 |
Neutral | 35 | 17 |
IMCI, Integrated Management of Childhood Illness.
A majority of the respondents (62%) had undergone the 11-day IMCI training and 38% underwent pre-service training.
Time spent on clients with and without using Integrated Management of Childhood Illness guidelines.
Response | Using IMCI guidelines consultation is quicker |
Not using IMCI guidelines consultation is quicker |
Value | ||
---|---|---|---|---|---|
% | % | ||||
Agree | 40 | 19 | 102 | 49 | < 0.001 |
Disagree | 157 | 76 | 91 | 44 | < 0.001 |
Neutral | 11 | 5 | 15 | 7 | 0.544 |
IMCI, Integrated Management of Childhood Illness.
, The two percentages differ significantly (Fisher’s exact test).
Challenges facing Integrated Management of Childhood Illness–trained professional nurses implementing the Integrated Management of Childhood Illness strategy.
Statement | Frequency | % |
---|---|---|
Agree | 192 | 92 |
Disagree | 10 | 5 |
Neutral | 6 | 3 |
Agree | 187 | 90 |
Disagree | 12 | 6 |
Neutral | 9 | 4 |
Agree | 92 | 44 |
Disagree | 95 | 46 |
Neutral | 21 | 10 |
Agree | 66 | 32 |
Disagree | 83 | 40 |
Neutral | 59 | 28 |
Agree | 98 | 47 |
Disagree | 90 | 43 |
Neutral | 20 | 10 |
Agree | 35 | 17 |
Disagree | 155 | 74 |
Neutral | 18 | 9 |
Agree | 19 | 9 |
Disagree | 179 | 86 |
Neutral | 10 | 5 |
Agree | 13 | 6 |
Disagree | 178 | 86 |
Neutral | 17 | 8 |
Agree | 23 | 11 |
Disagree | 165 | 79 |
Neutral | 20 | 10 |
Agree | 77 | 37 |
Disagree | 113 | 54 |
Neutral | 18 | 9 |
Agree | 26 | 13 |
Disagree | 169 | 81 |
Neutral | 13 | 6. |
Agree | 36 | 17 |
Disagree | 143 | 69 |
Neutral | 29 | 14 |
Agree | 71 | 34 |
Disagree | 109 | 52 |
Neutral | 28 | 14 |
Agree | 69 | 33 |
Disagree | 128 | 62 |
Neutral | 11 | 5 |
Agree | 152 | 73 |
Disagree | 44 | 21 |
Neutral | 12 | 6 |
Agree | 144 | 69 |
Disagree | 52 | 25 |
Neutral | 12 | 6 |
Agree | 75 | 36 |
Disagree | 103 | 50 |
Neutral | 30 | 14. |
IMCI, Integrated Management of Childhood Illness.
Recommendations to improve integrated management of childhood illness strategy implementation.
No. | Recommendations | Agree (%) | Disagree (%) | Neutral (%) |
---|---|---|---|---|
1. | Integration of IMCI into pre-service training | 84 | 8 | 8 |
2. | Scaling up of IMCI into pre-service training | 89 | 6 | 5 |
3. | Extending IMCI training to lower cadres of nurses in relation to their scope of practice, for example, auxiliary and enrolled nurse | 80 | 11 | 9 |
4. | Extension of IMCI training to senior manager | 93 | 3 | 4 |
5. | All nurses tending under-fives should be IMCI trained | 94 | 4 | 2 |
6. | IMCI used as a criterion for daily allocation of nurses | 61 | 26 | 13 |
7. | Provide facility layout that allows practice of all IMCI skills | 89 | 5 | 6 |
8. | Ensure availability of IMCI drugs, wall charts, booklet at all times | 94 | 4 | 2 |
9. | Address problem of understaffing | 92 | 5 | 3 |
10. | Follow-up and supervision of IMCI-trained nurses | 92 | 4 | 4 |
11. | IMCI national focal person should advocate for governmental policy support | 91 | 3 | 6 |
12. | IMCI national focal person should advocate for more resources from health planners | 92 | 3 | 5 |
IMCI, Integrated Management of Childhood Illness.
Respondents for this study included 208 IMCI-trained professional nurses working in the PHC clinics. Majority of the respondents were female (90%), and this could have been because of the fact that nursing in South Africa is a predominantly female profession.
A significant greater number of nurses (67%) reported that using the IMCI guidelines during their consultations took more time than when they were not using them. This finding is similar to those of previous studies that reported consultations to be more time-consuming when implementing the IMCI strategy as compared to traditional consultations.
Many (55%) respondents indicated that IMCI is only partially implemented as other children are treated by non-IMCI-trained professional nurses in their facilities. There is a plea from PHC clinics for trained IMCI professional nurses as indicated by 92% of the respondents. The same findings that indicated a lack of IMCI-trained staff were also found in other countries.
A majority of respondents (67%) believed that the IMCI strategy reduced the number of follow-up visits through accurate case management and that positive outcomes of the IMCI strategy were evident. Mupara
Half of this study’s respondents (50%) believed that it is not always practical to refer to IMCI guidelines when treating children below 5 years of age. This statement elicited mixed feelings among respondents. It was therefore important to further discover the challenges in the use of the IMCI guidelines.
Only 49% of respondents stated that all IMCI-trained professional nurses apply all stages of the IMCI guidelines. This statement indicates the limited application of the IMCI strategy by trained staff. This response was also reported in a study conducted in Indonesia including Uganda and Kenya that at times nurses did not fully assess or classify the child they were managing according to the IMCI guidelines.
Thirty-three per cent of the respondents stated that their facility’s layout did not make it easy to apply IMCI steps, such as observing the first treatment intake. The facility had limited space, and the respondents indicated that this was a barrier to IMCI implementation. It was also recommended by 89% of the study’s respondents that facility layout should be improved to promote IMCI strategy implementation. Several studies have also reported that a poor infrastructure is not conducive to IMCI implementation.
Despite the challenges experienced by IMCI-trained professional nurses, majority of the respondents (97%) also believed that IMCI boosted their confidence in skills and managing the under-five children. The same findings were cited in a study by Adekanye and Odetola,
Other challenges experienced included the question whether IMCI was regarded as too simplistic, and if it undermined their clinical skills, the majority (81%) responded in the negative manner, implying that IMCI was regarded as a necessary skill needed by professional nurses. The results concur with those of Mupara
Doctors are also implementing IMCI in South Africa. The study results also proved that doctors have positive attitude towards the strategy implementation as confirmed by 52% of respondents. This result is inconsistent with the study conducted in Kenya where participants of the study believed that doctors had negative attitudes towards IMCI implementation.
In contrast to the 44% of the respondents who agreed that the IMCI protocol is too long and time-consuming, 92% of the same respondents indicated that IMCI is user-friendly and a further 90% believed that IMCI strategy is easy to understand and apply. The study conducted by Mugala et al.
Supervisors are the integral part of IMCI implementation; therefore, they need to be IMCI-trained to understand the strategy. Eight-nine per cent of the respondents in the study indicated that their supervisor understood the rationale for using the IMCI strategy. However, the results also revealed that some supervisors were not IMCI-trained as indicated by 11% of respondents. A further 69% of respondents indicated that they lacked supervision of IMCI strategy implementation at their workplace after they were trained. It is therefore imperative to advocate for the IMCI training of clinic supervisors so that they can promote the IMCI strategy implementation and be able to supervise staff post-training. The finding is similar to that of several studies reporting national assessment surveys in Namibia, Kenya, Tanzania, Uganda and South Africa in which implementers of IMCI strategy also indicated that they lacked supervision.9,10, 19,24
World Health Organization
Resources are vital for adequate IMCI implementation. Although 62% of respondents indicated that the IMCI wall charts, chart booklet and IMCI drugs were available, 94% of the same respondents recommended that chart booklets should be available at the clinic for promoting the IMCI strategy. This finding may imply that these were unavailable at some centres and respondents could have been afraid to indicate their unavailability. The results of Titaley et al.
Human resource is required for the implementation of IMCI strategy; however, 46% of the respondents indicated that they had challenges with the patient–nurse ratio thereby creating a barrier to IMCI implementation. Surprisingly, a larger proportion (92%) suggested improving the patient–nurse ratio to promote IMCI implementation as the study recommendations. Goga and Muhe
Shortages of staff trained in the strategy lead to increased workload and thus compromise IMCI implementation. The provision of resources in PHC clinics, as well as conducting in-service training and supervising IMCI-trained staff, could promote the quality of care for under-five children through an improved IMCI implementation.
Measures that could be considered to address the desire of these nurses for improved IMCI training at all nursing levels include scaling up of IMCI training on the job. The extension of IMCI training should be made to lower cadres of nurses as they are the first contact of under-five children and could thus identify problems early and refer appropriately. In addition, senior nurse managers should be trained as they could help in the supervision and support of those implementing the programme.
Structural elements such as IMCI drugs should be prioritised by management as very important so that children less than 5 years old are treated appropriately using the prescribed drugs. Infrastructural budgets from the National Department of Health (NDoH) should be prioritised so that PHC clinics have adequate consulting rooms for IMCI services.
Processes such as supervision, in-service training and follow-up after training should be the responsibility of a district IMCI manager with a schedule honoured by all medical personnel.
Integrated Management of Childhood Illness–trained professional nurses find it difficult to implement the IMCI strategy despite their knowledge and acknowledgment of its benefits. Challenges that were shared included the fact that structural elements such as inadequate infrastructure, lack of IMCI drugs, shortages of material resources as well as human resources have a compromising effect on the quality of care rendered to under-five children. Process elements that are not conducted, such as in-service training, supportive supervision and follow-up after IMCI training, were reported to hamper IMCI strategy implementation by the majority of these respondents.
We would like to acknowledge all the participants who consented freely and actively participated in our research project.
The authors have declared that no competing interest exist.
L.T. collected and analysed the data. I.G. wrote the article. All the authors edited and approved the final manuscript.
The New Generation of Academics Programme (NGAP) Funding from the Department of Higher Education and Training and the National Research Foundation made this research possible.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.