Academic journal article Bulletin of the World Health Organization

Improving Antimicrobial Use among Health Workers in First-Level Facilities: Results from the Multi-Country Evaluation of the Integrated Management of Childhood Illness Strategy

Academic journal article Bulletin of the World Health Organization

Improving Antimicrobial Use among Health Workers in First-Level Facilities: Results from the Multi-Country Evaluation of the Integrated Management of Childhood Illness Strategy

Article excerpt

Voir page 513 le resume en francais. En la pagina 514 figura un resumen en espanol. [TEXT NOT REPRODUCIBLE IN ASCII.]

Introduction

Despite advances over the past few decades made in reducing child mortality, more than 10 million children die each year before they reach the age of five (1, 2). At least 6 in 10 of these deaths could be prevented if existing affordable interventions were available to all children who need them (3).

Antimicrobial drugs are one of the most powerful and important interventions available to reduce child mortality. Antibiotics are a proven treatment for pneumonia (4, 5), bacterial infections in neonates (6), the premature rupture of membranes (7) and for some cases of diarrhoea, including cholera, shigella dysentery, giardiasis and amoebiasis (8, 9). Antimalarials are needed to treat malaria in children (10, 11).

The increasing rate of biological resistance to antimicrobials has been recognized as a public health emergency. Studies have documented high levels of antibiotic misuse among health-care workers, such as using antibiotics to treat viral diseases or using incorrect dosages (12, 13). Thus one important strategy for slowing the development of resistance is to reduce the unnecessary use of these drugs (14-16). Efforts to reduce the prevalence of antimicrobial resistance in low-income and middle-income countries have increasingly focused on the promising approach of providing appropriate education for health workers (12, 17, 18).

Integrated Management of Childhood Illness (IMCI) is a strategy developed by WHO and UNICEF to provide effective and affordable interventions to reduce child mortality and improve child health and development (19). IMCI includes both preventive and curative interventions, and it is designed to improve the case-management skills of health workers, to strengthen health system supports for child health-service delivery, and to improve family and community practices related to child health (20).

Training health workers in IMCI case management has been conducted in more than 100 developing countries in both in-service and pre-service contexts (i.e., introducing IMCI into the basic education of doctors, nurses and other health professionals) (21). The training is based on a set of case-management guidelines that is adapted in each country prior to use. The training guides the health worker through a process of assessing signs and symptoms, classifying the illness based on treatment needs and providing appropriate treatment and education of the child's caregiver. The IMCI guidelines include information on identifying malnutrition and anaemia, checking vaccination status, providing nutritional counselling, and communicating effectively with caregivers (22). The training emphasizes supervised clinical practice, and in some settings health workers are visited in their facilities shortly after training to reinforce their new IMCI skills.

The multi-country evaluation (MCE) of IMCI effectiveness, cost and impact is a global programme designed to evaluate the impact of IMCI on child health and its cost-effectiveness (23). MCE studies are under way in Bangladesh, Brazil, Peru, the United Republic of Tanzania and Uganda.

In this paper we present selected results from MCE health-facility surveys in Brazil, the United Republic of Tanzania and Uganda. Our aim is to show that large numbers of children are receiving antibiotics through health providers, and that training in IMCI case management at first-level health facilities can lead to improved practices among health workers and improved knowledge among caregivers about how to continue antimicrobial treatment at home.

Methods

MCE study designs vary across the five countries depending on the stage of IMCI implementation and the opportunities available to use existing data. All sites measure a standard set of indicators using compatible survey tools (23). …

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