Do Healthcare Professional View Integrated Management of Childhood Illness Effective?Findings from in-Depth Interviews and Focus Group Discussion in Oman

Fannah Abdullah AlfannahMinistry of Health, Integrated Management Childhood Illness Expert, Department of Public Health, Muscat,Oman

Key words: Integrated Management of Childhood Illness(IMCI), Childhood illness, Primary Health Care (PHC),In-Depth Interviews (IDI), Focus Group Discussion(FGD), Knowledge Attitudes and Skills (KAS)

Corresponding Author:Fannah Abdullah AlfannahMinistry of Health, Integrated Management ChildhoodIllness Expert, Department of Public Health, Muscat,Oman

Page No.: 1-8Volume: 14, Issue 01, 2020ISSN: 1815-9346Research Journal of Medical SciencesCopy Right: Medwell Publications

Abstract: This study highlights the findings of a recentresearch effort where in-depth interviews and focus groupdiscussion were employed to examine views of healthcareprofessionals on the likely impact of IntegratedManagement of Childhood Illness (IMCI) on healthcareleadership in Blinded region, Oman. In-Depth Interviews(IDIs) and Focus Group Discussion (FGD) were chosenas appropriate methodologies to collect and analyze data.These methods suited the aim of the study and 12 (n = 12)healthcare professionals (8 male and 4 female) wererecruited, having more than 10 years of experience inintegrated management of childhood illness. In accordwith the best practice of qualitative research methodology,a specific question was developed to initiate discussionand gather participant’s knowledge and perceptions. Thefocal question was whether IMCI strategy could have apositive impact on healthcare leadership. The study wascarried out at Blinded Hospital, Sultanate of Oman inApril, 2017. All participants approved of IMCI strategyand believed that there is a positive correlation betweenthe strategy and improved child healthcare. In addition, allparticipants shared positive views on the impact of IMCIon leadership in the healthcare sector. Participants of thestudy strongly believed that IMCI strategy has: lead toenhanced strategic leadership and management at amacro level; improved Knowledge, Attitudes and Skills(KAS) of Primary Healthcare (PHC) workers, resulted inbetter prescription practices, prioritized the needs ofPrimary Healthcare (PHC) units, improved clinicalpractices and reduced unnecessary referrals. Resultsfrom the qualitative data analysis highlight theeffectiveness of IMCI strategy. The findings alsoindicate that IMCI strategy has a positive impact oncritical areas such as case management, KAS ofhealthcare professionals and child healthcare leadership.

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INTRODUCTION

Childhood illnesses continue to be a challenge in thearea of pediatric healthcare, consequently adding to theglobal disease burden[1]. The Integrated Management ofChildhood Illness (IMCI) strategy was introduced by theWorld Health Organization (WHO) in the year 1996[2].The strategy has been promoted, globally with an aim toimprove child healthcare[4]. It focuses on improvinghealthcare professional’s Knowledge, Attitudes and Skills(KAS) as well as refining healthcare systems by followingIMCI-recommended practices[4, 5]. A high majority of sickchildren (approximately 60%) can be saved usingaffordable and evidence-based medical interventions[4, 5].

We propose that IMCI strategy provides an opportunity toimprove child healthcare leading to higher survival rate inlow and middle-income countries[6]. IMCI strategy isdesigned in a way that it guides healthcare professionalsin effectively assessing and managing childhood illnessesby paying attention to the actual cause of the illness[7]. Inother words, healthcare professionals who are trained withIMCI focus on identifying and classifying an illnessbased on its severity by using the IMCI algorithm. Thisapproach helps healthcare professionals to adhere withcase-specific treatment. The IMCI algorithm wasdeveloped in a rather simple way through employing aseries of questions that can help diagnose criticalsymptoms[8, 9].

IMCI can be seen as a framework that is based ondemonstrated public health interventions[9]. The strategyhas been implemented in more than 100 countriesfollowed by several Multi-Country Evaluations (MCEs).Outcomes of the MCEs indicate its effectiveness inimproving child healthcare standards for example,improved healthcare professional performance[10].Literature indicates that IMCI-trained healthcareprofessionals tend to provide accurate and timelytreatment and guidance to sick children and theircaregivers, respectively[9]. Notwithstanding such findingsit is observed that anticipated results are yet to beachieved. This is because childhood mortality ratesremain high despite global adoption and implementationof IMCI strategy[11].

Findings from more recent studies reveal that somehealthcare professionals do not comply with theIMCI-recommended practices[12]. It could be deduced thathealthcare professionals with more traditional views havea tendency to rely on personal skills and practices whilemaking case assessments and diagnoses. If thisassumption stands true there is a manifest need toexamine and publish knowledge regarding healthcareprofessional’s views on potential impact of IMCI on childhealthcare, strategic leadership and management ofhealthcare systems.

We argue that child survival is subject to howhealthcare professionals perceive and practice IMCImethodology. Indeed, the knowledge and skills that theyreceive while being trained are important; however,perceptions can significantly influence actual practice ofthe acquired skills. Improved child healthcare requires aparadigm shift at the strategic level[13] and it is necessarythat new interventions are fully understood, implementedand practiced. It might be, so that, IMCI-trainedhealthcare professionals do not fully comply with theguidelines because they face a dynamic environment ona daily basis or might receive lack of supervision. It isemphasized over and again that appropriate supervisioncan help improve adherence leading to enhancedperformance by bridging the gap between knowledge andclinical practice[14]. Healthcare professionals and policymakers who perceive IMCI as being an effective strategycan become opinion leaders and further promote itspractice in a wider context.

Significant number of research articles highlightspositive impact of IMCI on improved child healthcare. InTanzania a 13% reduction in childhood mortality has beenlinked with IMCI-recommended practices[15]. Practice ofIMCI-recommended guidelines in clinical settings isalso accepted as a deciding factor for improving childhealthcare standards in other countries[16, 20]. Further,literature indicates a positive correlation betweenIMCI-guidelines and improved community healthpractices, correct prescriptions, reduced unnecessaryreferrals and better case assessment skills[17, 20, 21]. Despiteevident benefits of IMCI-recommended guidelines andpractices, optimal results are yet to be achieved.

One step towards this direction would be to exploreand understand how healthcare professionals foresee thescope of IMCI-training at a strategic level. We assumethat when healthcare professionals perceive IMCI as aneffective intervention they will support the strategy andencourage its implementation. In this study, we describethe perceptions and experiences of 12 (n = 12) healthcareprofessionals with a specific focus on the likely impact ofIMCI strategy on improving strategic leadership andmanagement in child healthcare sector. To the best of ourknowledge, no previous study has examined healthcareprofessional’s perceptions and experiences from this pointof view.

MATERIALS AND METHODS

The researcher conducted In-Depth Interviews (IDIs)and a Focus Group Discussion (FGD) with IMCI-trainedhealthcare professionals to explore their views andperceptions about IMCI strategy and whether theybelieved that the strategy has made a positive impact onchild healthcare in the region. The IDIs and FGD were

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conducted at Blinded Hospital, Oman in April, 2017.Ethical approval was obtained from the Ministry ofHealth, Oman prior to the study. All participants of thestudy had >10 years of experience in IMCI and wereworking different capacities in blinded region. Blindedregion was selected for the study for being a leader inIMCI implementation in the Sultanate. The IMCI focalpoint for blinded region was contacted prior to the study.The regional focal point helped in conducting theinterviews as well as focus group discussion. We carefullyselected the participants based on their experience withIMCI training and practice. This was done to ensure thattheir replies would provide rich insights and broaden thediscussions. This particular approach is in line withpurposive sampling strategies[22]. This particular strategyhelps researchers understand important cases rather thangeneral inferences from a set of specific populationsamples[23].

IDIs were chosen for collecting qualitative databecause the technique helps conducting detailedinterviews with a relatively small number of participantsin order to understand their opinions on a particularsubject or research question[24, 25]. Further, this techniquehelps gather data about participant’s perceptions,experiences and expectations about a specificintervention. In-depth interviews are also known for beinghighly useful when researchers aim to get detailed insights and understand individual opinions. At times it is alsoargued that this technique is suitable for situations whereconducting a focus group is not practical[24].

In addition to the in-depth interviews we opted toconduct a FGD. This research methodology was chosenas we had a small number of participants and ourobjective was to discuss a specific topic to gather andgenerate further ideas. Unlike individual in-depthinterviews, focus groups can provide an ideal platform forinteraction between different participants. Focus groupdiscussions are generally, accepted as a data collectiontechnique in the area of health and medical research[26]. Itis often argued that focus groups discussions lead todetailed responses when compared with direct questionsasked in individual interviews[27]. As qualitative researchis known for being a heterogeneous area whereresearchers are often left with no choice but to makecertain assumptions[28] focus groups are known for beingan effective research technique as they can be seen as agroup interview where carefully selected participantsshare their opinions, experiences, perceptions andattitudes towards a specific topic or area of research[28].The number of participants in the presented study was 12(n = 12) which is relatively small but large enough foreach participant to make significant contribution to thediscussion as proposed by Krueger and Casey[29].

Table 1: Basic demography of the participants from Blinded regionVariables Participants (N)GenderMale 8Female 4AgeYears 40-49Occupation/PositionHealth services (regional director) 1Primary health care (regional director) 1IMCI expert 3Pediatrician 2General physician 1Health education (regional in-charge) 2Nursing (regional in-charge) 1Pharmacist (regional in-charge) 1Experience in IMCI strategy >15 years

The overall research approach was qualitative anddescriptive in nature. Healthcare professionals fromblinded region were selected for participation and invitedto partake the study. All the invites agreed to participatein the study on a voluntary basis. The objective of thestudy was explained to the participants and informedconsent was obtained following international bestpractice. Prior to the actual study, we ran a pilot for bothIDIs and FDG to ensure that the questions and responseswould produce pertinent interactive discussions. Runninga pre-study pilot helped us refine key research questionsin addition to providing hands on training to the focusgroup moderator and note taker who plays a centralrole[28, 29] in such a research approach. The structure andcontent of both IDIs and FGD were prepared with thehelp of a healthcare researcher. A relatively simple formwas also prepared with four items, i.e. age, gender,occupation and experience in IMCI. For data analysis, wewrote down transcriptions and mapped common topicsthat were later used as representative quotes. All therecorded information and data were dealt with strictconfidentiality and used for the purpose of the studyonly. Table 1 exhibits some basic details about theparticipants.

RESULTS AND DISCUSSION

In-Depth Interviews (IDIs): Nearly all the participantsgave positive remarks about the impact of IMCI strategyand its benefits. They spoke about improved treatmentstandards, improvement in accurate and timely diagnosis,lower numbers of unnecessary referrals, bettertreatments at PHC level and so on. In addition, IDIsrevealed that there is a positive correlation betweenIMCI-recommended practices and improved strategicleadership and management of healthcare system. Ingeneral, findings from the interviews indicate a positivecorrelation between IMCI and improved child healthcarein the region. Below are some representative quotes:

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“There is a significant and noticeable reductionin unnecessary prescriptions which i feel is adirect consequence of complying with IMCIguidelines”

“IMCI guidelines are easy enough for today’smedical professionals. It is my personalobservation that IMCI-trained doctors have ahigher level of knowledge and understanding.Therefore, they focus on finding the root causerather than coming up with assumptivediagnosis and writing prescriptions”

In response to the impact of reduced prescriptionsand consumptions of drugs, the participants approved ofthe role of IMCI.

“Now that, we have IMCI-trained healthcareprofessionals, the positive implications can beseen at the pharmaceutical level. Even thepharmacies are receiving more attention in termsof improving infrastructure, storage capacitiesetc.”

“The fruits of implementing IMCI can be seenat both macro and micro levels in the region. Ifyou visit any of the PHC facilities, you will finda well-organized human resource allocation,improved infrastructure, lower turn over ratesand more satisfied caregivers. I find thisexciting as our aim is to provide sick childrenwith immediate but effective medical care andsurely IMCI guidelines facilitate the process”

Responding to the question about KAS, allparticipants gave strongly positive remarks.

“It is a result of the training and experience ofapplying IMCI guidelines that one can see anoverall improvement in knowledge, attitudesand skills of pediatricians when they arediagnosing a sick child and at the same timecounseling his/her parents”

“There is no doubt in my mind that IMCIstrategy has improved the KAS of both medics(doctors) and paramedic (nursing staff).Healthcare units have (consequently) becomeeffective, efficient and easier to manage. We arein a better position to provide immediate andaccurate medical treatment to sick children. Iguess, I would not be wrong if I were to say that IMCI guidelines and their actual implementationcan help us develop an integrated healthcare

system in the near future where we will havebetter tools, techniques and appropriate channelsof communication for furthering the healthcarefacilities and services”

Focus Group Discussion (FGD): Focus group discussionwas conducted to get a deeper understanding of how theparticipants responded to the questions during theirinteraction with other specialists/experts from the sameregion. Focus group discussions are frequently used tounderstand people’s viewpoints and to obtainclarifications that are relatively hard to get by askingdirect questions[27].

Focus group discussions suit healthcare research inparticular as majority of health-related conditions are aconsequence of societal situations[30]. Lastly, advantagesthat are generally associated with focus group discussionsinclude but are not limited to exchange of expert opinions,easily recordable discussions and collection of data in theform of ideas, suggestions and viewpoints about a specificissue. Following are the identified themes that emergedduring the focus group discussion:

Improved knowledge, attitudes and skills: All theparticipants responded with positive remarks in responseto the question, “Do you think that IMCI strategy has anyimpact on the knowledge, attitudes and skills ofhealthcare professionals?” Below are some of therepresentative quotes:

“There is an evident improvement in theknowledge and skills of healthcare workersas a result of practicing IMCI-guidelines. Myobservation is based on several years and nowthat I compare practitioners who haveexperience in IMCI, I find them with enhancedskills especially in case assessment”. (DirectorGeneral for Healthcare, Blinded Region)

“As a senior manager in the healthcare sector, Ihave observed that healthcare professionals,both doctors and nurses, have an improvedapproach when treating a (sick) child. This, inmy opinion, can be attributed to an integratedapproach of teaching and applying childhealthcare strategy (IMCI).” (Director of PHC,Blinded Region)

“I feel confident when I am dealing with a sickchild. I have no doubt that over the years, IMCIguidelines have helped me improve myprofessional skills especially in making accuratediagnosis”. (IMCI-trained Pediatrician, BlindedRegion)

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Reduced drug consumption: An overwhelming numberof positive remarks were received in response to thequestion, “Is there an impact of IMCI strategy on drugconsumption?” Some of the prominent responses arelisted below:

“Definitely! The amount of drug consumption is dropped down significantly overthe past years. This is indeed a positive outcomeof practicing IMCI strategy and guidelines”(In-charge of Pharmaceutical Department,Blinded Region)

“It (IMCI) has helped me follow a systematicpath (algorithm) to diagnose the root cause of anillness. Once a systematic diagnosis is made, ithelps prescribing drugs specific to the illness.So, I would be surprised if the overall drugintake is not reduced.” (IMCI-trainedPediatrician, Blinded Region)

“Yes, there is a noticeable reduction in drugconsumption in our region. This outcomehas multiple benefits. For me, I would say thatreduced drug intake (consumption) means thatI have more resources available for improvingthe hospital (healthcare) infrastructure,especially, the availability of essential drugs atpharmacies”. (Director of Primary Health Care,Blinded Region)

“Yes, there is a noticeable reduction in drugconsumption in our region. This outcome hasmultiple benefits. For me, I would say thatreduced drug intake (consumption) means thatI have more resources available for improvingthe hospital (healthcare) infrastructure,especially, the availability of essential drugs atpharmacies”. (Director of Primary Health Care,Blinded Region)

Allocation of resources: Improved resource allocationwas commonly voiced in response to the question “Isthere a relation between IMCI strategy and resourcemanagement?” Some of the representative quotes arestated below:

“The strategy (IMCI) has a wider impact on theoverall healthcare system. The benefits arenot just limited to a specific part (unit) ofthe healthcare structure. As a matter of fact,the benefits are far reaching. As a result ofintake (consumption), I find myself in a better

position to allocate resources to areas that needthem most. For example, I can allocate budgetfor infrastructure, timely and adequate suppliesof drugs and training needs of medical staffs”.(Director General Healthcare General forHealthcare, Blinded Region)

“I have access to more resources now ascompared with what I had about 10 years back.This is not just a coincidence. It is because weare following an integrated (IMCI) approach”.(Director General for Primary Health Care,Blinded Region)

“It has become easier to reach out to the seniormanagers when it comes to planning our day today operations. I believe the (IMCI) guidelineshave made our daily operations simpler andeffective.” (In-charge of PharmaceuticalDepartment, Blinded Region)

General comments: When given an opportunity todiscuss the impact of IMCI strategy on the regionalhealthcare system, all the participants were vocal andshared their views. The views revealed that theparticipants largely approved of the strategy. Theyhighlighted the positive impact of the strategy on amacro level. Some of the prominent quotes are presentedbelow:

“The impact of IMCI teaching and practicing onimproving referrals is manifest. From the timethat, we started following (practicing) thestrategy in the region, there is a noticeablereduction in unnecessary referrals”.(IMCI-expert, Blinded Region)

“The benefits are for everyone. Paramedic staffsthat are trained with IMCI have better skills ascompared with those who were trained withthe vertical teaching style. However, themanagement has encouraged and supported allto get (IMCI) training. I also want to add thatnow (today) both medical doctors and nurseshave become better counselors. They give betteradvice to the caregivers and as a result wewitness higher number of follow up visits”.(In-charge of Nursing Education and Training,Blinded Region)

“IMCI trained healthcare professionals are moreconfident. It is my understanding that they feelempowered and skilled for performing theirduties effectively. This makes life easier for a

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senior manager, for example, a healthcare unitin-charge who has a skilled team can spendmore time on planning and implementingstrategic decisions.” (Director General ofPrimary Health Care, Blinded Region)

“When we talk about sick children, we simplycannot overlook their parents (immediatecaregivers). IMCI guidelines have made ourdoctors and nurses better at communication andgiving advice. This in turn has resulted inbuilding a stronger relationship between thecommunity and healthcare professionals. They(parents/immediate caregivers) not only listen tothe advice but also act on it. The action can betraced when the make follow up visits. I amconvinced that community has more confidencein healthcare facilities that we now provide.”(Director General for Healthcare, BlindedRegion)

“I have no doubt that IMCI implementation hasresulted in better management of resources, costeffectiveness and improved health indicators”.(Director of Primary Health Care, BlindedRegion)

RESULTS AND DISCUSSION

This study was performed to explore views,perceptions and experiences of healthcare professionalsabout the impact of IMCI-strategy on healthcare systemas well as strategic leadership. The participants includedsenior healthcare managers, medical practitioners, IMCIexperts, pediatricians and nursing educators. Allparticipants approved of IMCI-strategy and acknowledgedits positive impact on the overall healthcare standard. Thisfinding is similar to other research findings that haveidentified benefits of implementing IMCI-strategy[31,33]

where improved KAS, better diagnostic practices andenhanced community engagement are often discoursed.All participants agreed that IMCI being a holisticapproach for managing child healthcare has multiplebenefits. Participants also acknowledged that theapproach is far more effective when compared with thetraditional (vertical) teaching methodology when itcomes to diagnosing a sick child and making accuratediagnosis.

According to the participants, IMCI strategy hassignificantly reduced unnecessary referrals and drugconsumption and as a consequence there are moreresources available for health care managers to focus onmaking strategic decisions related with improvinginfrastructure, planning human resources and engaging

community, especially, immediate caregivers. Thesefindings are similar to MCEs that have highlighted similaroutcomes[34, 35]. From the in-depth interviews and focusgroup discussion it is observed that healthcareprofessionals perceive IMCI strategy as an effectiveinitiative that not only improves child healthcare but hasdirect implications for healthcare managers.

For example, it was repeatedly reported thathealthcare managers are in a better position for allocatingresources at primary health care units. Further, it washighlighted that even the pharmacies are well equippednow as a consequence of IMCI strategy implementation.Almost all the participants supported IMCI as a keycontributor for improving strategic leadership in thehealthcare sector. They frequently related accuratediagnosis with reduced drug consumption which in theiropinion makes more resources available to healthcaremanagers for improving related areas such as improvingthe healthcare facilities, providing IMCI training to newstaff members and engaging with the community moreeffectively. Indeed, community engagement remains anessential part of the IMCI strategy[36].

CONCLUSION

The study highlights that Integrated Management ofChildhood Illness (IMCI) strategy is acknowledged as aneffective technique for improving child healthcare.Likewise, the findings indicate that there is a positivecorrelation between IMCI-teaching strategy and improvedstrategic child healthcare leadership. Lastly, the findingsindicate that when implemented and practiced, although,it might take sometime, IMCI benefits the entirehealthcare system including primary healthcare units,immediate caregivers and indeed sick children.

ACKNOWLEDGEMENTS

The researcher would like to thank all of theparticipants for their cooperation as well as the relevantauthorities of the Ministry of Health, Oman. In addition,the researcher appreciates the efforts of the healthcareprofessionals who aided in the development andvalidation of the questionnaire items.

LIMITATIONS

This study has its limitations. First, it was performedin one region that is known to be among the leaders inpracticing IMCI-recommended guidelines. Therefore, atpresent it is not possible to generalize the findings.Secondly, we did not include a community representativein the study, therefore, a potential bias cannot beoverruled. Lastly, the sample size is evidently small;however, in-depth interviews and especially focus groupdiscussions support such a sample size, especially whenthe participants are specialists/experts in a particular area.

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We do however, emphasize that the prime objective of thestudy was to examine the views of healthcareprofessionals about the effectiveness of IMCI strategy. Itis for this reason that the results highlight ratherdescriptive responses.

IMPLICATIONS

While the implications for practice might be observedas beyond the findings of the study, they do neverthelesspave the way for further studies at a larger scale.Therefore we plan to perform another study wheremajority of the participants will be from the community.It would be interesting to collect their responses andcompare with the findings of this study.

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