Academic journal article Bulletin of the World Health Organization

The Integrated Management of Childhood Illness in Western Uganda

Academic journal article Bulletin of the World Health Organization

The Integrated Management of Childhood Illness in Western Uganda

Article excerpt


In developing countries, five diseases (pneumonia, diarrhoea, malaria, measles and malnutrition) cause the majority of deaths in under-5-year-old children. Specific programmes have reduced the mortality from respiratory infections, diarrhoea and vaccine-preventable diseases (1-3), and control programmes have successfully established standard disease-specific guidelines for diagnosis and treatment of diarrhoea and respiratory infections using simple signs and symptoms to guide primary health care workers (3-6). However, there are no guidelines in general use for managing children with other common and potentially fatal diseases, or for the child with multiple conditions. Health workers receive little guidance on how to integrate diagnostic and therapeutic guidelines developed by disease-specific programmes. A new integrated approach, the Integrated Management of Childhood Illness (IMCI), earlier called Integrated Management of the Sick Child, has therefore been developed jointly by WHO and UNICEF (7, 8). This approach incorporates the existing guidelines for management of diarrhoea and respiratory diseases and adds new guidelines for measles, malaria, malnutrition and anaemia into a single comprehensive case management approach. For measles, the diagnosis is based on the presence of fever, a rash, and red eyes. In areas hyperendemic for malaria, diagnosis is based on a history of fever in the previous 24 hours. In this study, the criterion for anaemia is pallor of the palms or conjunctiva. Malnutrition is based on a weight-for-age Z-score of -2 or worse; severe malnutrition is based on visible severe wasting or the presence of bipedal oedema.

The IMCI approach begins with the health worker inquiring about the presence of danger signs: lethargy or coma, convulsions, inability to drink, or persistent vomiting. The presence of a danger sign indicates urgent need for referral to hospital. Next, the health worker assesses and classifies the child's illness(es), selects appropriate treatment, and provides advice to the child's carer.

A preliminary version of the IMCI algorithm (June 1994) was used by medical assistants to assess and classify the illnesses of 1226 children aged 2-59 months in the outpatient clinic of a district hospital in western Uganda.(a) We report how this use of the IMCI algorithm compared with a medical officer's assessment based on a full history and physical examination, supplemented by laboratory and radiographic studies.

Patients and methods

Kabarole District Hospital, the largest of three hospitals serving a predominantly rural area with 750 000 inhabitants, is the referral facility for 38 outlying district health units and provides primary care to the residents of Fort Portal, the district's largest town. Daily, this hospital's outpatient department deals with 15-25 under-5-year-olds. From 15 August 1994 to 27 January 1995, a systematic sample of children aged 2-59 months (variously 67%, 75% or 80% of all children, depending on the anticipated daily attendance) were selected for inclusion in the study. Verbal informed consent was obtained from the child's carer.

Clinical assessments were carried out by two medical assistants and four general medical officers. The medical assistants were secondary school graduates with three years of medical assistant training and 18-36 months of clinical experience. Immediately prior to commencement of the study, an intensive five-day training to use the assess and classify component of the algorithm was conducted. Continuous supervision was provided to monitor the work of the two medical assistants and resolve any difficulties. The four Ugandan medical officers had 7-13 years of clinical experience after medical school. Regular meetings were held so that the medical officers could address problems they encountered in the study.

On enrollment of a child into the study, one of the two medical assistants assessed and classified the complaints and clinical findings using a single-page record adapted from the IMCI wall chart. …

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