2009 05 13 100812macaso, Janice - R.

THE EFFECTIVENESS OF A MODIFIED INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS TRAINING WORKSHOP IN IMPROVING THE

KNOWLEDGE AND SKILLS OF BARANGAY MIDWIVES
REGARDING ASSESSMENT, CLASSIFICATION AND
TREATMENT OF COMMON CHILDHOOD
ILLNESSESS IN DAPITAN CITY,
ZAMBOANGA DEL NORTE
A Research Paper Presented

to
The Faculty of
Ateneo de Zamboanga University-
School of Medicine
In Partial Fulfillment of the

Requirements for the Degree
DOCTOR OF MEDICINE
Submitted by:
Janice Rebollos Macaso

March 09, 2009
TABLE OF CONTENTS
PAGE
TABLE OF CONTENTS 2
LIST OF TABLES AND FIGURES 3
ABSTRACT 4
CHAPTER I INTRODUCTION 5
Background of the Student 5
Statement of the Problem 7
Objectives of the Study 7
Significance of the Study 8
Limitations of the Study 9
Definition of Terms 10
Conceptual Framework 11
CHAPTER II REVIEW OF RELATED LITERATURE 12
CHAPTER III METHODOLOGY 16
Research Design 16
Respondents 17
Sampling Design 17
Research Instrument 17
Flow of Activities 19
Statistical Analysis 20
Limitations 20
CHAPTER IV RESULTS AND DISCUSSION 21
CHAPTER V CONCLUSIONS AND RECCOMENDATIONS 31
i
ADZU-SOM RESEARCHES/LEVEL42009/MACASO,JANICE R.
BIBLIOGRAPHY 32
APPENDICES 34
LIST OF TABLES
Table 1 Demographic Profile of the Respondents Page 21
Table 2 Paired-sample T-test Results of Pre and Post

Intervention Evaluation for Knowledge Page 22
Table 3 McNemar’s Test for Item Analysis of Knowledge Page 23
Table 4 McNemar’s Test for Item Analysis of Skills Page 26
Table 5 McNemar’s Test for Pre and Post Intervention

Evaluation for Skills Page 27
LIST OF FIGURES
Figure 1 Conceptual Framework Page 11
Figure 2 Flow of Activities Page 19
ii
Abstract
This study was focused on the implementation of a modified version of the DOH training
program called Integrated Management of Childhood Illness (IMCI). It was done to determine
the effectiveness of the said program in improving the knowledge and skills of midwives
regarding assessment, classification and treatment of common childhood illnesses in the
community. The selected respondents involved all midwives serving in the different barangay
health stations of Dapitan City, who were trained with a two day intensive seminar on the IMCI
protocol. Pre and post evaluations were done through a 20-item written exam and a 6-item
checklist used by the researcher for hands on evaluation for skills of the respondents. Results of
pre and post evaluations were analyzed using a paired sample t-test. For the written
evaluations,12 out of 17 respondents passed the pre-intervention evaluation for knowledge with
a mean score of 12.24, after intervention, 16 out of 17 respondents passed the written evaluation
scoring 12 and above from the 20-item exam giving a mean score of 14.06. Comparing the mean
scores of the respondents during the pre and post intervention evaluation for knowledge, a
calculated p-value of 0.008 was obtained. And for the actual hands-on evaluations, only 1
respondent passed during the pre-intervention evaluation with a mean score of 2.17, after
intervention 14 out of 17 respondents passed the actual hands-on evaluation for skills with a
mean score of 4.29, a p-value of 0.000 was obtained after comparing the pre and post
intervention mean scores of the respondents , both knowledge and skills regarding IMCI after
intervention showed significant improvement .
iii
CHAPTER I
INTRODUCTION
Background
Every year millions of children die on a daily basis, especially in developing countries,
such as the Philippines. Although the rate of child mortality has decreased over the years since
the 1970’s, the sad truth is that such decrease is unequally distributed throughout the world. In
fact according to World Health Report in the year 1999, children in under-developed countries
have ten times the risk of dying before even reaching the age of five. Such deaths on a global
scale reach a count of roughly ten million mortalities, seven out of ten are due to one of the
following top five morbidities: respiratory infection, diarrhea, measles, malaria and malnutrition
– most oftenly even a combination of these. The sad truth remains that such morbidities could
actually be prevented by simple health education and prevention.
This truth is apparent even here in the Philippines. And although morbidity and mortality
have significantly decreased over the years due to the innovative breakthroughs of oral
rehydration solutions, programs on breastfeeding and on the expanded program on
immunization, there is still a significant number of children who die every year due to
preventable diseases. This is often brought about by the fact that children most likely would
present at health facility, not with just a single isolated health problem, but with an integration of
several problems. And in barangay level, such treatment given to these children often are isolated
from each other, failing to meet the child’s needs as a whole.
1
The Integrated Management of Childhood Illness (IMCI) is a program with an integrated
approach targeted to the population most vulnerable to morbidity and mortality, those five years
old and younger, focusing on the well being of the child as a whole. Spearheaded during the
early 1990’s by UNICEF, WHO and other world health organizations, the IMCI was developed
as a training tool with three main components, geared to improve case management skills of
health care staff, improve the overall health system of a given community, and as well as
improve family and community health practices, taking on many forms, and may be tailored to
fit a specific country’s health situation.
At present, the IMCI has been introduced to more than seventy five countries around the
world, and is actively being conducted in Brazil, Bangladesh, Peru, Uganda, to name a few. To
date, the IMCI program has been implemented in the Philippines in several communities over a
span of 6 year. During this timeframe, no evaluation has yet been done to determine whether or
not such intervention is effective for the Philippine setting or specific rural community setting.
The current research aimed to address the issue of the effectiveness of the IMCI in
improving the knowledge and skills of barangay midwives assigned to the communities of
Dapitan City, Zamboanga del Norte. Subjects were trained through the use of the mentioned
program, and evaluation tools were developed by the researcher to determine the effectiveness of
the IMCI in addressing the health problems of our local community setting.
2
Research Question:
Is the Modified Integrated Management of Childhood Illness (IMCI) training workshop
effective in improving the knowledge and skills of barangay midwives regarding assessment,
classification and treatment of common childhood illnesses in Dapitan City, Zamboanga Del
Norte?
General Objectives:
To determine the effectiveness of a Modified Integrated Management of Childhood
Illness (IMCI) training workshop in improving the knowledge and skills of barangay midwives
regarding assessment, classification and treatment of common childhood illnesses in Dapitan
City, Zamboanga Del Norte
Specific Objectives:
a. to determine the knowledge of midwives regarding assessment, classification and
treatment of common childhood illnesses in Dapitan City before and after the
modified IMCI training workshop.
b. to determine the skills of midwives regarding assessment, classification and treatment
of pneumonia in Dapitan City before and after the modified IMCI training workshop.
c. to compare the knowledge of midwives regarding assessment, classification and
treatment of common childhood illnesses in Dapitan City before and after the
modified IMCI training workshop.
d. to compare the skills of midwives regarding assessment, classification and treatment
of pneumonia in Dapitan City before and after the modifed IMCI training workshop.
Hypothesis:
3
Null Hypothesis: There is no significant difference between the knowledge and skills of
barangay midwives regarding assessment, classification and treatment of common childhood
illnesses and their skills on assessment, classification and treatment of pneumonias in Dapitan
City, Zamboanga Del Norte before and after the modified IMCI training workshop.
Alternative Hypothesis: There is a significant difference between the knowledge of barangay
midwives regarding assessment, classification and treatment of common childhood illnesses and
their skills on assessment, classification and treatment of pneumonia in Dapitan City,
Zamboanga Del Norte before and after the modified IMCI training workshop.
Significance:
The current research deals with an educational method of intervention through 2 separate
lecture seminars and an interactive video training workshop of the IMCI catered to the barangay
midwives of the communities of Dapitan City. The said training focused on the top morbidities
in the Philippines among children 5 years old and below, emphasizing assessment, classification,
treatment, referral and counseling regarding these diseases. This paper has devised a screening
tool to determine the effectiveness of a modified IMCI training workshop for midwives from
rural communities like Dapitan City . However this strategy needs to be tested as to its
effectiveness and it is this information which the current research will provide.
Furthermore, this paper could also open doors to further study on the program of IMCI,
and how to make the training available to rural community health workers considering that the
local government has no adequate budget to allocate for a 2-week stay-in IMCI training and also
to further improve it and tailor it to fit the setting of the Philippines . It will determine whether or
not such approach to the health situation of our country is effective, henceforth promoting its
further implementation in the rural communities.
4
Scope and Delimitations
The present study is a pre and post interventional study, determining whether or not there
is a significant improvement on the knowledge of barangay midwives regarding assessment,
classification and treatment of common childhood illnesses and their skills on assessment,
classification and treatment of pneumonia before and after the modified IMCI training
workshop. Such intervention is in the form of a 2-part lecture seminar and a 1-part video training
workshop utilizing a certified IMCI training instructor and materials provided by the DOH.
This is limited to the barangay midwives, assigned to serve in the different barangay health
centers of Dapitan City.
The evaluations will be conducted in two phases, the first of which would be before the
interventions, and the second phase would be held after the interventions. These evaluations are
in the form of a 20-item questionnaire for the respondents to answer, with multiple choice and
true or false questions, as well as a 6 item checklist for the researcher to be used for actual hands-
on evaluation. The former will involve questions regarding assessment, classification,
management and referral of the most common morbidities in the community, namely pneumonia,
diarrhea, fever caused by measles or dengue, malnutrition, and ear infections The actual
evaluation on the other hand will focus only on the evaluation of pneumonia, the most commonly
seen case in the health centers.
5
Definition of Terms:
Integrated Management of Childhood Illness (IMCI): is a program of integrated approach to
child health that focuses on the child’s well being as a whole. It aims to reduce death, illness and
disability and to promote and improve growth and development among children five years old
and below, involving both preventive and curative elements implemented on families,
communities and health facilities. It addresses the top morbidities of a given community, such as
respiratory infections, diarrhea and malnutrition, dealing with proper disease prevention and
health promotion in the different levels of society, from the family setting, to the setting of the
health center, the hospital, and the community as a whole.
The training proper for this program lasts for 2weeks or so, requiring participants (health
care givers) to stay in a hotel or convention center where the seminar is held and a 3-5 days
rotation on a tertiary hospital where the participants are required to handle real cases of the
diseases included in the program.
Modified Integrated Management of Childhood Illness training workshop : a 2-day training
workshop using the IMCI protocol, the lectures and training workshop was conducted by a
certified IMCI trainer utilizing educational materials and tools from the Department of Health
Region IX.
6
Conceptual Framework:
MODIFIED INTEGRATED
MANAGEMENT OF CHILDHOOD
ILLNESS TRAINING WORKSHOP
NO NO Improved Improved
improvement improvement knowledge of skills of
in the in the skills barangay barangay
knowledge of of barangay midwives midwives
barangay midwives regarding regarding
midwives regarding assessment, assessment,
regarding assessment, classification classification
assessment, classification and treatment and treatment
classification and treatment of common of
and treatment of childhood pneumonia
of common pneumonia illnesses
childhood
illnesses
Figure 1: conceptual framework
Explain
7
CHAPTER II
REVIEW OF RELATED LITERATURE
An article by Lambrechts T, Bryce J and Orinda V (1999) entitled Integrated
Management of Childhood Illness: A Summary of First Experiences describes the
aforementioned program as a strategy aiming to reduce child mortality and morbidity in under
developed countries by combining management of common childhood illnesses with proper
immunization and nutrition. Such intervention is geared to address skills of health workers in the
local community setting, the health system itself, and improve family and community health
practices. According to this article, the IMCI is composed of three phases, first of which is the
introduction of the IMCI program, where guidelines to health policies and interventions in the
local setting is reviewed and reorganized. Second is the initial implementation, where each local
setting adopts the generic IMCI training protocol and guidelines to fit their specific health
situation and starts the implementation. Thirdly, it involves expanding the IMCI program while
maintaining quality and development.
In the setting of Dapitan City, these phases will be undergone one by one in
implementing and establishing the IMCI as a training tool for the midwives of this community,
with the hopes of determining whether or not this is an effective approach to the local health
problems.
Another article entitle Integrated Management of Childhood Illness; a Review of the
Ethiopian Experience and Prospects for Child Health (Lulseged, 2002) describes the
implementation of the IMCI program in Ethiopia during the year 1997. in this setting, it was
found out that most of childhood illness and death were associated with pneumonia, diarrhea,
malaria, measles and malnutrition. With such a situation, the IMCI has been adopted as the main
8
strategy to deal with these health issues in three regions of this country. Several points have been
discovered, as areas which need improvement, such as the need for scaling up training activities
and carry out follow up after training in 4-6 weeks. It was also mentioned that a standardized
checklist needs to be developed and integrated to serve as indicators of the effectiveness of the
program.
Such data shows that this relatively young interventional approach to health problems
still has much room for development and improvement. The weak points mentioned could be
taken into account in this paper when it would be adopted in the setting of the community of
Dapitan.
One study encountered entitled Effect of Integrated Management of Childhood Illness on
Observed Quality of Care of Under-fives in Rural Tanzania by Armstrong et al (2004) compares
two different community settings in the Republic of Tanzania. One of which had the benefit of
receiving the IMCI training program, while the other simply made use of the existing health care
services of that community. Through the Multi-Country Evaluation of IMCI Effectiveness, Cost,
and Impact (IMCI-MCE), they monitored the IMCI program implementation in the said setting.
Results indicate that children in communities with the IMCI program received better care
than those in other districts: health problems were more thoroughly assessed, had proper early
diagnosis and referral to the appropriate health facilities, received proper treatment, and
caretakers of the children reported to have higher levels of knowledge of how to care for their
sick children. Such study shows that the IMCI program is a feasible intervention in poor
countries, which can lead to rapid improvement in case management, suggesting effectiveness in
the community setting.
9
El Arifeen et al (2004) in a research entitled Integrated Management of Childhood Illness
in Bangladesh: Early Findings From Cluster-Randomised Study writes of the comparison of
areas in the mentioned country where IMCI was implemented, with those communities that have
not received this intervention. Results show that the use of the IMCI program increased child
visitation at local health centers, initially from 0.6 baseline visits per child per year, to 1.9 visits
per child per year in about 21 months of IMCI introduction. 19% of sick children in the IMCI
area were taken to the health workers, compared to only 9% in non-IMCI areas.
Such data shows the effectiveness of the IMCI program in improving health seeking
behavior among the community, a result that could be expected in the implementation of this
program in the community of Dapitan City.
A study conducted by Naimoli et al (2006) entitled Effect of the Integrated Management
of Childhood Illness Strategy on Health Care Quality in Morocco was done in order to evaluate
the IMCI clinical guidelines and identify other factors influencing quality of health care received
by children in the mentioned setting. Results show that quality of health care was far better in the
provinces of Morocco where IMCI was implemented, showing correct drug and antibiotic
prescription, among other improvement indicators. The major findings were that the intervention
was strongly associated with overall adherence to guidelines and correct drug prescription in 6-
12months post intervention.
Such outcome shows that IMCI is effective in improving health care promotion by the
local health workers, a goals that the researcher hopes to achieve through the current research.
In conclusion, the review of related literature included papers which have shown the
actual implementation of the IMCI in different countries around the world. It has shown that this
program is relatively new, and is subject to more improvement and proper evaluation of its
10
effectiveness. However several researches have established the fact that the IMCI program is an
effective means of intervention on dealing with health problems in under developed countries.
11
CHAPTER III
METHODOLOGY
Research Design
This study is a pre and post interventional study involving the use of a modified version
of a seminar workshop program called the Integrated Management on Childhood Illness (IMCI).
Training was focused on the barangay midwives assigned in the different rural communities of
Dapitan City. The purpose of this intervention was to improve the knowledge of these mentioned
care givers in the areas of assessment, classification, and treatment of common childhood
morbidities seen in the community setting and their skills on assessment, classification and
treatment of pneumonia. The goal is to determine whether or not such intervention is an effective
tool in improving the health situation of our communities.
The mentioned seminar workshop involved 2 sessions of lectures delivered by Dr.
Domiciano P. Talaboc, the MHO of Polanco, Zamboanga del Norte, who is a certified IMCI
trainer. These lectures were held one week apart from each other. In addition, there was a 1 video
session, where what was lectured on was shown through video, presenting documented cases of
the different morbidities covered by the IMCI training. Such video used is the official video
presentation used during IMCI training by the DOH.
To evaluate the effectiveness of the intervention, a written and actual pre intervention
evaluation was done before the modified IMCI training, followed by a post intervention of the
same evaluations used prior. Results were analyzed and compared to determine any significant
improvement in both knowledge and skill of the barangay midwives. The written exam was
composed of a 20 item multiple choice and true or false questionnaire. The actual exam in turn
was composed of a 6 item checklist, where the researcher herself evaluated each respondent by
12
observing them manage actual pneumonia cases in their respective health stations. It is vital to
stress that the written evaluations covered the 5 most common morbidities in the communities,
which is also covered by the IMCI, namely pneumonia, acute gastroenteritis, fever caused by
measles and DHF, malnutrition and ear infections. The actual evaluation on the other hand only
evaluated pneumonia, the top morbidity in the city of Dapitan. This is due to the limited time the
researcher had in conducting the research, as well as considering the far locations of each
barangay midwife and their respective health stations.
Respondents:
All barangay midwives employed by the City Health Office serving in the different
health centers of Dapitan was included in this study, a total of 20 midwives. However 3 dropped
out of the study due to absences during the interventions. A total of 17 were left to be included in
the final analysis.
Sampling Design:
This study used the sampling design of total count, involving all barangay midwives
assigned to the communities of Dapitan, 20 in all.
Research Instrument:
Questionnaire
The first research instrument that was utilized was the training protocol for Midwives on
the Integrated Management of Childhood Illness. This program is an integration of programs
dealing with the whole child, addressing the top 5 morbidities common among pediatric patients
13
ages 5 and below. The program has currently been established in some 70 or so underdeveloped
countries worldwide, and is tailored to fit each individual community’s specific needs.
The IMCI has been established in the Philippines for some 6 or so years now,
spearheaded by the Department of Health. Numerous training sessions are being conducted
monthly around the country to promote the IMCI. But despite this, there has been no evaluation
tool developed to identify whether or not this program is indeed effective.
The current study involved tapping the DOH, seeking aid in the training sessions to be
conducted among the barangay midwives of Dapitan City.
Checklist
The second tool to be utilized will be evaluation tools for the midwives who will receive
the mentioned training on IMCI, given as a pretest before the IMCI training, and as a post test
administered after the training. These involved a 20 item multiple choice and true or false
questionnaire, and a checklist for actual evaluation. It served to measure significant changes in
the knowledge and skill of the respondents with regard to their abilities to assess, classify,
manage and refer cases involving the top morbidities in the community, namely fever (caused by
dengue and measles), diarrhea, pneumonia, malnutrition and ear infections. It must be clarified
that the written exam covered the aforementioned morbidities above, while the actual exam only
covered pneumonia, the most common morbidity in the city of Dapitan. This is due to time
constraint as well as the far flung locations of each barangay midwife and their respective health
stations.
The questionnaire is composed of 12 “must know” items, a respondent is considered to
have passed the written exam if he or she has achieved a score of at least 12 out of 20 correct
14
items, while he or she is considered to have passed the actual exam if the respondent achieved a
score of at least 4 out of 6 correct items.
15
Flow of Activities:
Consent from Mayor and City

Health Officers of Dapitan City
Tap DOH Region IX to seek aid

in providing trainers for IMCI
Seek consent from Dapitan City Health

Office to invite midwives for training
Produce evaluation tools to determine the

effectiveness of the IMCI program
Pre-test evaluations
Intervention: training of midwives on

IMCI protocol
Post-test evaluations
Analysis of data and writing of paper
Figure 2: flow of activities
16
Statistical Analysis
In order to determine a significant improvement in knowledge and skills of the barangay
midwives before and after the intervention, a paired t-test will be used to compare pretest and
posttest scores and McNemar’s test was also used for item analysis.
Limitations:
The current research involves the use of a modified IMCI training tool targeted upon the
barangay midwives assigned in the different communities within the city of Dapitan. With the
mentioned training tool, the researcher hopes to determine whether or not this form of training
workshop is an effective intervention in helping solve the health problems of the rural
communities of the Philippines. This will be achieved through the pretest and posttest written
and OSCE evaluations of the respondents, to measure change in knowledge and skills of
midwives regarding their health practice and health promotion involving the top morbidities of
the communities.
The present study will only include barangay midwives, in order to ensure their literacy
in being able to comply with the modified training workshop of the IMCI. It will only address
midwives actively assigned to the different barangays of Dapitan. Data from the current study
may not be generalized to include other midwives outside of the mentioned research setting, nor
does it include health care providers other than barangay midwives outside the current study.
17
CHAPTER IV
RESULTS AND DISCUSSION
Upon seeking the approval of the City Mayor and the City Health Office, all barangay
midwives of the entire Dapitan City were gathered and subjected to the IMCI training. A total of
17 respondents were included in the study selected by total count.
Table 1. Demographic Profile of Respondents
Classification Distribution of Respondents
N=17
Age Group
30-40 years old 9 (53%)
41-50 years old 2 (12%)
51-60 years old 5 (29%)
61-70 years old 1 (6%)
Year in Service
1-10 years 6 (36%)
11-20 years 5 (29%)
21-30 years 5 (29%)
31-40 years 1 (6%)
As shown in table 1, all respondents are female who finished Bachelor degree in
Midwifery. In terms of age, majority of the respondents belongs to the younger range
18
which is from 30 to 40 years old and there were greater number of respondents who are
still in their early years in service (1 to 10 years).
On October 24, 2008 and October 31, 2008 the midwives were given a lecture on IMCI
training by Dr Talaboc, a certified IMCI trainer. On the same date, October 31, 2008 an
interactive video training was also conducted. Pre-intervention and post-intervention evaluations
were given to the respondents to measure improvement in their knowledge and skills of handling
top childhood morbidities in the communities.
Table 2. Results of Pre and Post Intervention Evaluation for Knowledge
# of respondents who
passed Mean Scores P-value
N= 17
PRE 12 (70%) 12.24

0.008
POST 16 (94%) 14.06
* P- value of <0.05 means “significant”
Table 2 presents the comparison of results obtained by the respondents between
the pre and post intervention evaluations and the number of respondents who passed the
evaluation for knowledge, which means that the respondent scored at least 12 correct answers
out of the 20 questions included in the questionnaire. As shown in the table, there is a significant
increase in the mean scores of the respondents from 12.25 to 14.06, this was a significant
increase based on the Paired sample T-test (p-value < 0.05).
19
Table 3. Item analysis for Knowledge Questions
Knowledge # of respondents with correct answer P-value

questions (N=17)
PRE POST
Danger Signs to 14 (82%) 17 (100%) 0.250
look in a child age 5
years and below
General danger
signs indicating 17 (100%) 17 (100%) ---------
serious problem
Sign of Severe 14 (82%) 11 (65%) 0.508
pneumonia
Counting of RR 15 (88%) 15 (88%) 1.000
Treatment for
pneumonia 2 (12%) 15 (88%) 0.000
Character of stool in
Diarrhea 16 (94%) 17 (100%) 1.000
Classification of Px
with diarrhea 1 (6%) 4 (24%) 0.250
Classification with
treatment of Px 16 (94%) 16 (94%) 1.000
with diarrhea
Assessment of
Fever 15 (88%) 14 (82%) 1.000
Duration of Fever in 7 (41%) 0 0.016
DHF
Signs of measles 8 (47%) 14 (82%) 0.070
Assessment of DHF 14 (82%) 14 (82%) 1.000
Complications of
measles 14 (82%) 17 (100%) 0.250
Assessment of Px
with ear problem 14 (82%) 7 (41%) 0.065
Signs of acute ear
infection 2 (12%) 4 (24%) 0.625
Classification of 6 (35%) 3 (18%) 0.37

malnutrition
Cause of anemia 9 (53%) 16 (94%) 0.016
Classification of
anemia 3 (18%) 5 (29%) 0.727
Schedule for DPT
vaccination 15 (88%) 17 (100%) 0.500
Importance of Vit.A 7 (41%) 14 (82%) 0.039
* P- value of <0.05 means “significant”
* P- value of >0.05 means “not significant”
20
The above table presents the specific items comprising the 20-item questionnaire for
knowledge evaluation. The number of respondents who obtained a correct answer for specific
item during pre and post intervention is also indicated. At baseline, as shown in the table,
majority of the respondents already had adequate knowledge on specific areas of the IMCI
program such as on items as follows: on identifying danger signs in children 5 years old and
below where 14 out of 17 respondents (82%) answered correctly, all of the respondents answered
correctly on the item regarding danger signs as an indicator for a serious problem in a child,
same with the item on the classification of pneumonia where 82% of the respondents and
counting of respiratory rate where 88% of the respondents answered correctly. Out of 17
respondents, 16 (94%) correctly answered the items on classification and treatment of patients
with diarrhea and character of stool in diarrhea. There were also 88% of the respondents who
answered correctly the items regarding schedule for vaccination with DPT and assessment of
fever. Out of 17 respondents, 14 (82%) correctly answered the items regarding assessment of
DHF and patients with ear problem and complications of measles. On the other hand, majority of
the respondents was not able to answer 9 of the listed items correctly. These are items regarding
duration of fever in DHF, signs of measles, signs of acute ear infection, classification of
malnutrition, causes of anemia, classification of anemia and importance of vitamin A. Only 6 to
47% of the respondents answered correctly on these items.
After intervention, a decrease of number of respondents with correct answer is noted on
several items: duration of fever in DHF, where after intervention not one respondent answered
correctly, signs of severe pneumonia where from 82 to only 65% of the respondents answered
correctly, assessment for fever, 88% to 82% of the respondents answered correctly, assessment
21
of patient with ear problem from 82 down to only 41% of the respondents answered correctly
and finally, the item on the classification of malnutrition where from 35% to only 18% or 3 out
of 17 respondents answered the item correctly. On the other hand, an increase in the number of
respondents with correct answers is noted on item regarding dangers signs in children 5 years old
and below, where after intervention 100% of the respondents answered correctly, other items
with improvement after intervention are as follows: treatment for pneumonia, character of stool
in diarrhea, classification of patients with diarrhea, signs of measles, complication of measles,
causes and classification of anemia, schedule for DPT vaccination and importance of Vitamin A.
Table 4. Item analysis for Skills
Skills Assessed # of Respondents who were correct P-value

N=17
PRE POST
Assessment for --------
Fever 17 (100%) 17 (100%)
Assessment for --------
Cough 17 (100%) 17 (100%)
Counting of
Respiratory Rate 1 (5%) 16 (94%) 0.000
Prescription of
correct Antibiotic
and Dosage 1 (5%) 8 (47%) 0.016
Advising mothers to
use safe home
remedy to soothe
throat 4 (24%) 4 (24%) 1.000
Advising for follow-
up check up 2 (12%) 8 (47%) 0.109
As shown in the above table, at baseline, 100% of the respondents had adequate skills on
assessment for fever and cough. But improvements noted in terms of skills of midwives in
handling cases of pneumonia is on counting the respiratory rate of patients where 94% or 16 out
of 17 acquired the skill after intervention. On the skill of prescribing correct medications for
22
pneumonia, there was an increase of number of respondents who were correct on this item, from
1 out of 17 respondents to 8 out of 17, however, the great percentage of the respondents (53%)
still don’t know this item despite the training. Take note that for the last 2 items, advising
mothers on safe home remedy and follow-up check ups, there was no significant improvement.
Table 5. Pre and Post Intervention Evaluation for Skills
# of respondents
# of Items on who passed P-value
Checklist (scoring 4 points
and above)
N= 17
PRE 6 1 (6%)
0.000
POST 6 14 (82%)
Table 5 presents the comparison of results obtained by the respondents between the pre
and post intervention evaluations and the number of respondents who passed the evaluation for
skills, paired-sample t-test was used for analysis. As presented in the table, there is a significant
increase in the number of respondents who passed the evaluation from 1 respondent during the
pre-intervention to 14 respondents who scored 4 point and above in the checklist after the
intervention, this was a significant increase based on McNemar’s test result (p-value < 0.05).
23
DISCUSSION
Spearheaded by the World Health Organization, and having been adopted by the DOH to
fit our tertiary communities, IMCI program has been running for six to seven years now. During
the entire duration of this time, no evaluation tools have been done to determine whether or not
the IMCI program is indeed effective for use in our communities. The purpose of this entire
research has been to remedy this issue.
The respondents involved in this study were all midwives employed in the City Health
Office who were deployed to man barangay health centers in the different communities of
Dapitan City. One limitation identified in this study is that the respondents were not homogenous
according to their number of years in service with a wide range of 1 year to 40 years serving in
barangay health centers, this factor however may have been minimal since none of the
respondents went through the IMCI training.
The tools for evaluation in this study were in the form of a 20-item questionnaire for
knowledge and a 6-item checklist for skills. Pre and post intervention evaluation was done and
results were analyzed using Paired-sample T-test and McNemars Test for item analysis.
During the pre-intervention evaluations for knowledge, 12 out of 17 respondents
satisfactorily passed having a raw score of 12 and above, while 5 failed as shown in Table2.
After the IMCI training 16 respondents passed and only 1 failed. Statistical analysis showed a
calculated P-value of .008 allowing the researcher to conclude that generally, there was a
significant improvement in knowledge after intervention. However, after subjecting the data for
item analysis, McNemar’s test showed that majority of the respondents already had adequate
knowledge regarding the topics included in the IMCI program. Comparison of the number of
24
respondents who answered correctly on the specific items included in the questionnaire to
evaluate knowledge of the respondents was done. It was noted that there is no significant
increase of knowledge, item per item, regarding IMCI. One reason maybe because the topics
included in the IMCI program are “practical topics” for any health worker and DOH
continuously conduct seminars for midwives and other health workers about topics which are
also included in the IMCI, like for instance the CARI protocol, Diarrhea and Oral Rehydration,
Dengue Fever etc. The respondents in this study may have been exposed to one or more of these
seminars thus increasing their knowledge about the said topics.
On the other hand, pre-intervention results for the actual evaluations utilizing the 6-item
checklist showed that only 1 respondent satisfactorily passed, while 16 failed. However after the
IMCI training, repeat evaluations yielded better results, where 14 passed and only 3 respondents
failed. Comparing pre and post intervention results, using McNemars Test, yielded a P-value of
0.000, showing a similar improvement and a significant difference in pre and post intervention
scores.
There are a few items in the checklist for which the researcher would like to zero in. The
item on drug prescription showed that during the pre and post evaluations, majority (53%) of the
respondents did not improve in their skill of prescribing the correct medications for pneumonia.
As the researcher has observed, most of the health centers do not have any drug supplies for the
treatment of pneumonia, as a result, the barangay midwives after the diagnosis of pneumonia
would automatically refer these patients to the city health office or the hospital, where
medications are available. This is probably the main reason why majority of the respondents
failed in the item of drug prescription, as in their situation, they do not have any drugs to
prescribe.
25
The second item that needs explanation is that referring to the skill on advising mothers
on the use of home remedies for pneumonia. Majority of the respondents have also performed
poorly in this area, as the prevailing belief among the midwives is that other than the medications
for pneumonia, all other alternative treatment such as home remedies do not have any effect.
This has to do with their trying to be “professional health care givers” who do not result to herbal
and alternative medicine.
The third item on advising mothers to seek follow up check ups also showed that
majority faired poorly in this area. This is in connection with the item on drug prescription. As
mentioned earlier, midwives would refer their pneumonia patients to the hospitals and city health
offices where they could receive available medications, due to the fact that most health centers
lack these supplies. It is also understood by these midwives that since their patients would get
their drugs from the hospital or city health office, their follow up would also be in these same
areas, and not with the barangay health centers.
In summary, comparing both written and actual evaluation results administered before
and after the IMCI training, a significant improvement has indeed been identified generally in
both knowledge and skill of the respondents.
26
CHAPTER 5
CONCLUSION AND RECOMMENDATION
This study aimed to determine the effectiveness of a modified IMCI training program in
improving the knowledge of barangay midwives regarding assessment, classification, and
treatment of common childhood illnesses and their skills on assessment, classification and
treatment of pneumonia in the community. In conclusion, the modified IMCI training workshop
was proven to improve knowledge of midwives regarding common childhood illnesses, and their
skills on the assessment of fever, cough and proper counting of respiratory rate on cases of
pneumonia among children age 5 years and below.
It is the recommendation of this paper to further modify the IMCI training for health
workers in our local communities. It is also recommended that further research be done in the
complete evaluation of this program, in a longer span of time. One limitation of the current paper
is that post evaluation was done merely once due to time constraint and the distance of the
midwives serving in different barangays around Dapitan. Ideally post test evaluations should be
done time and time again as to determine whether such training truly is effective.
The IMCI training, which was tailored to fit the tertiary communities of the Philippines,
is a good training tool for all health practitioners, not just in the rural areas, but in the urban areas
as well. It is an intensive training module that covers five of the top causes of morbidities among
children 5 years old and below. It emphasizes on early detection and identification of danger
signs and symptoms of these diseases, as well as classification, early intervention and when to
refer these cases to doctors and hospitals. By catering to the early identification of children 5
years and below, morbidity is significantly avoided
27
BIBLIOGRAPHY
Integrated Management of Childhood Illness.

http://www.redcross.org/services/intl/imci/damm.asp
Integrated Management of Childhood Illness

http://en.wikipedia.org/wiki/Integrated_Management_of_Childhood_Illness
Lambrechts T, Bryce J., Orinda V 1999. Integrated management of childhood illness: a

summary of first experiences.
http://www.ncbi.nlm.nih.gov/pubmed/10444882
J Health Popul Nutr. 2001 Research to support household and community IMCI. Report of a
meeting, 22-24 January 2001, Baltimore, Maryland, USA.
http://www.ncbi.nlm.nih.gov/pubmed/11503353?ordinalpos=3&itool=EntrezSystem
2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Bryce J, Victora CG, Habicht JP, Black RE, Scherpbier RW2005 Programmatic pathways to
child survival: results of a multi-country evaluation of Integrated Management of
Childhood Illness.
2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discov
ery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed
Lulseged S. 2002 Integrated management of childhood illness: a review of the Ethiopian

experience and prospects for child health.
Heiby JR. Quality improvement and the integrated management of childhood illness: lessons
from developed countries.
http://www.ncbi.nlm.nih.gov/pubmed/9626619?ordinalpos=8&itool=EntrezSystem2.
PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Bull World Health Organ. 1997 Integrated management of childhood illness: conclusions.
WHO Division of Child Health and Development.
http://www.ncbi.nlm.nih.gov/pubmed/9529725?ordinalpos=7&itool=EntrezSystem2.
PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Armstrong Schellenberg J, Bryce J, de Savigny D, Lambrechts T, Mbuya C, Mgalula L,

Wilczynska K; Tanzania 2004. The effect of Integrated Management of Childhood
28
Illness on observed quality of care of under-fives in rural Tanzania.
Robinson D. 1996 The integrated management of childhood illness.

http://www.ncbi.nlm.nih.gov/pubmed/12291734?ordinalpos=19&itool=EntrezSyste
m2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
El Arifeen S, Blum LS, Hoque DM, Chowdhury EK, Khan R, Black RE, Victora CG,
Bryce J. 2004 Integrated Management of Childhood Illness (IMCI) in Bangladesh: early
findings from a cluster-randomised study.
Huicho L, Dávila M, Gonzales F, Drasbek C, Bryce J, Victora CG. 2005 Implementation of

the Integrated Management of Childhood Illness strategy in Peru and its association with
health indicators: an ecological analysis.
Joseph F. Naimoli, Alexander K. Rowe, Aziza Lyaghfouri, Rijimati Larbi and Lalla Aicha
Lamrani 2006
http://intqhc.oxfordjournals.org/cgi/content/full/18/2/134
29
APPENDICES
30
IMCI Module for Midwives
QUESTIONNAIRE for Knowledge
Name: ______________________________________
Date: ________________
Brgy. Health Center:___________________________
Instruction: Encircle the correct answer for each item.
1. Which of the following is a danger sign?

a. the child is coughing
b. the child is not able to drink or breastfeed
c. the child has rashes
d. the child has fever
2. A child with a general danger sign has a serious problem. TRUE or FALSE?
3. Fast breathing is a sign of Severe pneumonia. TRUE or FALSE?
4. How many minutes should you count the breaths of a child who have cough or difficult
breathing?
a. as needed
b. 5 minutes
c. 1 minute
d. 2 minutes
5. Which of the following is included in the treatment of a child with SEVERE PNEUMONIA?
a. refer Immediately to the hospital
b. give an appropriate antibiotic for 5 days
c. give first dose of an antibiotic and refer urgently to hospital
d. advise mother to follow-up in 2 days
6. Diarrhea occurs when stools contain more water than normal. TRUE or FALSE
7. A child with diarrhea who is restless, irritable with sunken eyes and drinks eagerly is classified
as:
a. with No dehydration
b. with some dehydration
c. with severe dehydration
d. none of the above
31
8. A child with diarrhea with NO dehydration DOES NOT need ORS (oral rehydration solution).
TRUE or FALSE.
9. A child with axillary temperature of 37.1ºC is considered to have FEVER.

TRUE or FALSE
10. Children with DHF (Dengue Hemorrhagic Fever) have fever which may last for how many
days?
a. 3-5days
b. 1-3days
c. 2-7days
d. 1-4days
11. The following are signs suggesting MEASLES EXCEPT:

a. generalized rash with cough
b. generalized rash with red eyes
c. generalized rash with stiff neck
d. generalized rash with runny nose
12. You should assess for DHF all children two months of age or older with fever in areas where
there is a risk of DHF. TRUE or FALSE.
13. Vitamin A deficiency contributes to some of the complications of measles such as corneal
ulcer. TRUE or FALSE.
14. A child with ear problem is assessed for:

a. ear pain and discharge
b. hearing loss
c. fever
d. all of the above
15. The following are signs of ACUTE EAR INFECTION EXCEPT:

a. ear pain
b. Pus draining from the ear and discharge is reported for less than 14days
c. Tender swelling behind the ear.
16. When the child has protein-energy malnutrition:
a. the child may become severely wasted, a sign of marasmus.
b. the child may develop edema, a sign of kwashiorkor.
c. the child may not grow well and become stunted.
d. all of the above
32
17. A child can develop anemia as a result of:
a. Ear infection
b. Dehydration
c. Parasitic infection
d. None of the above
18. A child with some palmar pallor or very low weight for age is classified as:
a. Severe malnutrition or severe anemia
b. Anemia or very low weight
c. No anemia and not very low weight
19. DPT-2 vaccine should be given to a child at what appropriate age?

a. 6 weeks
b. 14 weeks
c. 10 weeks
d. 9 months
20. Vitamin A is important because:

a. it plays a vital role in the growth and development of children
b. it helps prevent infections
c. all of the above
33
IMCI Checklist for Skills
Name _________________________________________
Date: ________________
Barangay Health Center: __________________________________________
A. NO PNEUMONIA
COUGH/COLDS
BASIS:
1. Cough assessment:
____history taking
2. (+)/ (-) Fever
____hx of fever asked, temp taken
3. No signs of pneumonia or severe pneumonia ____
RR counted, 1 full minute
TREATMENT:
1. Refer for assessment if coughing for >30days
2. Soothe the throat and relieve the cough with a safe remedy
3. Advise mother when to return
a. follow-up in 5days if not improving
B. PNEUMONIA
BASIS:
1. Cough assessment: ______
hx taking
2. Fever ______
hx of fever asked, temp taken
3. Fast Breathing ______
RR counted for 1 full minute
a. 0-2mos: >60 BPM
b. 2mos-1 yr: >50 classification: ______
w/ pneumonia
c. 1-5 yrs: >60
TREATMENT:
34
1.Give an appropriate antibiotics for 5days treatment:
______ prescribed correct meds/dosage
a. First-line antibiotic for pneumonia is COTRIMOXAZOLE, give 2X daily for 5

days.
Dosage:
Age Tablet
Syrup
80mg trimethoprim 40mg
trimethoprim
+ 400mg sulphamethoxazole +
200mgsulphamethoxazole per 5 ml
2mos – 12mos
(4-<10 kg) ½ tab 5 ml
12 months up to 5 years
(10-19kg) 1 tab 10 ml
b. Second-line antibiotic for pneumonia is AMOXYCILLIN, give 3X daily for 5 days
Dosage:
Age Tablet
Syrup
250mg 125mg
per 5 ml
2mos – 12mos
(4-<10 kg) ½ tab 5 ml
12 months up to 5 years
(10-19kg) 1 tab 10 ml
2. Soothe the throat and relieve the cough with a safe remedy _____
advised remedy
3. Advise mother to return immediately _____
advised follow-up
a. advise for follow-up in 2days
35

2009 05 13 100812macaso, Janice - R.

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2009 05 13 100812macaso, Janice - R.

Uploaded by

Copyright:

Available Formats

THE EFFECTIVENESS OF A MODIFIED INTEGRATED MANAGEMENT OF

CHILDHOOD ILLNESS TRAINING WORKSHOP IN IMPROVING THE

A Research Paper Presented

In Partial Fulfillment of the

Janice Rebollos Macaso

LIST OF TABLES AND FIGURES 3

Background of the Student 5

Statement of the Problem 7

Objectives of the Study 7

Significance of the Study 8

Limitations of the Study 9

CHAPTER II REVIEW OF RELATED LITERATURE 12

CHAPTER III METHODOLOGY 16

CHAPTER IV RESULTS AND DISCUSSION 21

CHAPTER V CONCLUSIONS AND RECCOMENDATIONS 31

Table 1 Demographic Profile of the Respondents Page 21

Table 2 Paired-sample T-test Results of Pre and Post

Table 3 McNemar’s Test for Item Analysis of Knowledge Page 23

Table 4 McNemar’s Test for Item Analysis of Skills Page 26

Table 5 McNemar’s Test for Pre and Post Intervention

Figure 1 Conceptual Framework Page 11

Figure 2 Flow of Activities Page 19

regarding assessment, classification and treatment of common childhood illnesses in the

intervention showed significant improvement .

actually be prevented by simple health education and prevention.

rehydration solutions, programs on breastfeeding and on the expanded program on

from each other, failing to meet the child’s needs as a whole.

fit a specific country’s health situation.

Is the Modified Integrated Management of Childhood Illness (IMCI) training workshop

To determine the effectiveness of a Modified Integrated Management of Childhood

regarding assessment, classification and treatment of common childhood illnesses in Dapitan

City, Zamboanga Del Norte

a. to determine the knowledge of midwives regarding assessment, classification and

modified IMCI training workshop.

b. to determine the skills of midwives regarding assessment, classification and treatment

c. to compare the knowledge of midwives regarding assessment, classification and

modified IMCI training workshop.

d. to compare the skills of midwives regarding assessment, classification and treatment

barangay midwives regarding assessment, classification and treatment of common childhood

Alternative Hypothesis: There is a significant difference between the knowledge of barangay

their skills on assessment, classification and treatment of pneumonia in Dapitan City,

further implementation in the rural communities.

is a significant improvement on the knowledge of barangay midwives regarding assessment,

centers of Dapitan City.

on evaluation. The former will involve questions regarding assessment, classification,

seen case in the health centers.

Integrated Management of Childhood Illness (IMCI): is a program of integrated approach to

health center, the hospital, and the community as a whole.

diseases included in the program.

Modified Integrated Management of Childhood Illness training workshop : a 2-day training

Figure 1: conceptual framework

REVIEW OF RELATED LITERATURE

An article by Lambrechts T, Bryce J and Orinda V (1999) entitled Integrated

Management of Childhood Illness: A Summary of First Experiences describes the

developed countries by combining management of common childhood illnesses with proper

maintaining quality and development.

Another article entitle Integrated Management of Childhood Illness; a Review of the

One study encountered entitled Effect of Integrated Management of Childhood Illness on

Observed Quality of Care of Under-fives in Rural Tanzania by Armstrong et al (2004) compares

the community setting.

in Bangladesh: Early Findings From Cluster-Randomised Study writes of the comparison of

program in the community of Dapitan City.