University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA ADHERENCE TO THE USE OF INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESSES (IMNCI) PROTOCOL AMONG HEALTH WORKERS IN ASHIEDU-KETEKE AND ABLEKUMA SUBMETROS, ACCRA BY CHARLOTTE ELEANOR ODEIBEA OKAE (10269466) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA IN PARTIAL FULFILLMENT OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Charlotte Eleanor Odeibea Okae, do hereby declare that, with the exception of cited literature, which is acknowledged, this dissertation is the result of my own original research under the supervision of Dr. John Kuumouri Ganle. This work has neither in part nor in whole been presented elsewhere for any other purpose. …………………………….. Date……………............. Charlotte Eleanor Odeibea Okae (Student) ………………………….. Date…15/10/2018…… Dr. John Kuumouri Ganle (Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I wish to dedicate this work to God Almighty who gave me the strength to go through this course successfully. Secondly to my sister and two sons: Mrs. Florence Okae Addotey, Nana Yaw Wiafe Akenteng and Papa Yaw Wiafe Akenteng. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGMENT I give thanks to the Almighty God for his mercy and abundant grace to complete this programme successfully. I also wish to express my sincerest gratitude to my supervisor, Dr. John Kuumouri Ganle for the effective supervision, advice, and recommendations to shape this dissertation. I am indeed grateful. I express my appreciation to the entire lecturers and staff of the School of Public Health for their support throughout the period of studies. I recognize and thank the management and health staff of Princess Marie Louis Children Hospital, Ussher, Mamprobi and Dansoman Polyclinics. I am most grateful to my family and Mrs. Martina A-Danoo for their love and encouragement throughout this period. I want to extend my heartfelt gratitude to my roommate Pearl Vondee for the care, support and love shown me during this course. Finally to all my friends and mates especially Bernard Tagoe, Mavis Narh, Mildred Arday, Ignatius Terence Ako-Nnubeng and Prince Osei for their support and inspiration in diverse ways to make this dissertation a success. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: In Ghana, one in every twelve children dies before their fifth birthday despite the implementation of the IMNCI protocol since 1998. Studies to investigate this in Ghana have focused on specific aspects such as laboratory test and management of malaria with limited attention paid to assessing health workers’ knowledge and adherence to the three focal areas in the IMNCI strategy. Objectives: This study assessed knowledge and adherence as well as factors associated with the use of the Integrated Management of Childhood and Neonatal Illness (IMNCI) protocol among health workers caring for children under five years in Ashiedu-Keteke and Ablekuma Sub metropolis in the Greater Accra Region. Methods: A health facility-based cross-sectional quantitative survey using a self- administered questionnaire was employed. Data was collected from 300 randomly sampled health workers who directly provide child healthcare in four public health facilities in the Ashiedu-Keteke and Ablekuma sub-metropolis of the Greater Accra region. Descriptive statistics, chi-square and logistic regression analyses performed at a confidence level of 95% and a P<0.05 was considered as statistically significant. Results: Findings suggest that 56.7% of the respondents had a low level of knowledge on IMNCI. Adherence to the IMNCI protocol was also low (58.7%). Factors associated with adherence to the use of the IMNCI protocol were age, the location of health facility, and level of knowledge on IMNCI. Health workers aged 18-29 were less likely to adhere to the protocol compared to those aged above 40 (AOR: 0.07; 95% CI: 0.01 - 0.28). Respondents who worked at Ussher Polyclinic were less likely to adhere to the protocol than those working at Princess Marie Louis Children’s Hospital (AOR: 0.14; 95% CI: iv University of Ghana http://ugspace.ug.edu.gh 0.05 – 0.39). Health workers who had high level of knowledge on IMNCI protocol were more likely to adhere than those who had low knowledge (AOR: 2.70; 95% CI: 1.51 – 4.84). Conclusion: This study has revealed that both knowledge on, and adherence to, the protocol IMNCI among healthcare workers caring for children under five in the study area are low. If quality healthcare delivery to children under five years in the health facilities studied is to be ensured, it is important that healthcare providers not only become aware and knowledgeable about the IMNCI protocol but also adhere to the protocol in the delivery of healthcare to children. Routine in-service training of healthcare providers on the IMNCI protocol could improve both improve both knowledge on, and adherence to, the protocol IMNCI. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION................................................................................................................ i DEDICATION................................................................................................................... ii ACKNOWLEDGMENT ................................................................................................. iii ABSTRACT ...................................................................................................................... iv LIST OF TABLES ........................................................................................................... xi LIST OF FIGURES ........................................................................................................ xii LIST OF ABBREVIATIONS ....................................................................................... xiii CHAPTER ONE ............................................................................................................... 1 INTRODUCTION............................................................................................................. 1 1.1. Background: ................................................................................................................. 1 1.2. Problem Statement ....................................................................................................... 4 1.3. Objectives of Study ...................................................................................................... 6 1.3.1. General Objective .......................................................................................................... 6 1.3.2. Specific Objectives ........................................................................................................ 6 1.4. Research Questions ...................................................................................................... 7 1.5. Justification .................................................................................................................. 7 1.6. Chapter Summary ........................................................................................................ 8 vi University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO .............................................................................................................. 8 LITERATURE REVIEW ................................................................................................ 9 2.1. The burden of neonatal and childhood morbidity and mortality ................................. 9 2.2. Strategies for reducing neonatal and childhood morbidity and mortality .................. 11 2.2.1 Expanded Programme on Immunization of Children Under-five Years ...................... 11 2.2.2 Early Initiation of Breastfeeding and Exclusive Breastfeeding.................................... 13 2.2.3 Continuum of care ........................................................................................................ 13 2.2.4 Integrated Community Case Management of Childhood Illness (ICCM) .................... 16 2.3. The IMNCI and its Components ................................................................................ 17 2.4. Impact of IMNCI ....................................................................................................... 19 2.5. Knowledge and attitude to IMNCI in management of children under five years ...... 20 2.6. Adherence to the IMNCI protocol in the management of children under five years 21 2.7 Factors influencing IMNCI adherence ........................................................................ 21 2.8 Conceptual Framework ............................................................................................... 23 2.9 Chapter Summary ....................................................................................................... 24 CHAPTER THREE ........................................................................................................ 26 METHODS ...................................................................................................................... 26 3.0. Introduction ................................................................................................................ 26 vii University of Ghana http://ugspace.ug.edu.gh 3.1. Study design ............................................................................................................... 26 3.2 Study area.................................................................................................................... 27 3.3 Study population ......................................................................................................... 28 3.3.1 Inclusion criteria ........................................................................................................... 28 3.3.2. Exclusion criteria: ........................................................................................................ 28 3.4 Determination of sample size...................................................................................... 28 3.5. Sampling Procedure ................................................................................................... 29 3.6. Data Collection Methods and Tools .......................................................................... 31 3.7 Pretest of Data Collection Instrument ......................................................................... 32 3.8. Quality assurance ....................................................................................................... 32 3.9. Variables .................................................................................................................... 32 3.10. Data analysis ............................................................................................................ 34 3.11. Ethical consideration ................................................................................................ 36 3.12. Chapter Summary .................................................................................................... 37 CHAPTER FOUR ........................................................................................................... 38 RESULTS ........................................................................................................................ 38 4.0 Introduction ................................................................................................................. 38 4.1 Socio-demographic characteristics of respondents ..................................................... 38 viii University of Ghana http://ugspace.ug.edu.gh 4.2 Awareness and Training on IMNCI ............................................................................ 39 4.3 Knowledge on IMNCI components ............................................................................ 41 4.3.1 Knowledge on child or neonate assessment ................................................................. 43 4.3.2 Knowledge on classification and treatment of neonatal and childhood illnesses ......... 44 4.3.3 Overall knowledge on IMNCI ...................................................................................... 46 4.4 Adherence to use of IMNCI among respondents ........................................................ 52 4.5 Factors associated with adherence to IMNCI protocol ............................................... 55 4.6 Chapter summary ........................................................................................................ 60 CHAPTER FIVE ............................................................................................................ 61 DISCUSSION .................................................................................................................. 61 5.1 Introduction ................................................................................................................. 61 5.2 Summary of findings................................................................................................... 61 5.3 Consistency with previous research ............................................................................ 62 5.4 Explanation of findings and implications ................................................................... 64 5.5 Strengths and limitations............................................................................................. 65 5.6 Chapter summary ........................................................................................................ 66 CHAPTER SIX ............................................................................................................... 67 CONCLUSION AND RECOMMENDATIONS .......................................................... 67 ix University of Ghana http://ugspace.ug.edu.gh 6.1 Conclusion .................................................................................................................. 67 6.2 Recommendation ........................................................................................................ 68 6.2.1 Policy Recommendations ............................................................................................. 68 6.2.2 Clinical Practice Recommendations ............................................................................. 68 6.2.3 Recommendation for further Research ......................................................................... 69 REFERENCES ................................................................................................................ 70 APPENDICES ................................................................................................................. 76 Appendix I: Participant Information Sheet and Consent Form ........................................ 76 Appendix II: Study Questionnaire .................................................................................... 80 Appendix III: Letter of Ethical Clearance ........................................................................ 86 x University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Description of dependent variable of interest ................................................................. 32 Table 2: Description of independent variables of interest ............................................................ 33 Table 3: Socio-demographic characteristics of respondents ......................................................... 39 Table 4: Knowledge on IMNCI components ................................................................................ 42 Table 5: Knowledge on child assessment ..................................................................................... 43 Table 6: Knowledge on classification and treatment .................................................................... 45 Table 7: Socio-demographic characteristics associated with level of knowledge on IMNCI (Bivariate analysis) ....................................................................................................................... 49 Table 8a: Factors associated with level of knowledge on IMNCI (Logistic regression analysis) 51 Table 8b: Factors associated with level of knowledge on IMNCI (Logistic regression analysis) 51 Table 9: Adherence to IMNCI protocol ........................................................................................ 53 Table 10: Adherence to IMNCI protocol (Continued) ................................................................. 54 Table 11: Bivariate analysis of factors associated with adherence of IMNCI protocol ............... 56 Table 12a: Logistic regression analysis of factors associated with IMNCI adherence ................ 58 Table 12b: Logistic regression analysis of factors associated with IMNCI adherence ................ 59 xi University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Integrated Three Components of IMNCI protocol (Source: WHO, 2003) ................... 18 Figure 2: Conceptual framework illustrating factors that may influence adherence to the use of IMNCI Protocol ............................................................................................................................ 23 Figure 4: Percentage distribution of respondents by training on the IMNCI protocol ................. 41 Figure 5: Box plot showing composite scores for knowledge on IMNCI components ................ 42 Figure 6: Box plot showing the composite score for knowledge on child assessment ................. 44 Figure 7: Box plot showing the composite score for knowledge on classification and treatment 46 Figure 8: Composite scores on overall knowledge on IMNCI ..................................................... 47 Figure 9: Respondents’ Overall level of knowledge on IMNCI ................................................... 48 Figure 10: Box plot of composite scores for adherence to IMNCI protocol ................................ 55 xii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ALRI - Acute Lower Respiratory Infection CPD - Continuous Professional Development EPI - Expanded Programme on Immunization GDHS – Ghana Demographic Health Survey GHS – Ghana Health Service GSS - Ghana Statistical Service HCW - Health Care Worker ICCM - Integrated Community Case Management of Childhood Illness IMNCI – Integrated management of neonatal and child illnesses IQR - Interquartile Range MDG – Millennium Development Goals MOH - Ministry of Health NDPC - National Development Planning Commission PML - Princess Marie Louis Children’s Hospital UN - United Nations UNICEF - United Nations Internal Children’s Emergency Fund USAID - United States Agency for International Development WHO - .World Health Organization xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1. Background: Over the years, progress in the reduction of neonatal and infant mortality rates has posed major public health challenges. In developing countries, these rates remain very high despite several interventions (Lawn et al, 2010). This is partly because comorbidities are common among sick childhood conditions (Shewade, Aggarwal, & Bharti, 2013). Hence, comprehensive assessments and combined treatment are often required to be successful (Ketsela, Habimana, Martines, Mbewe, & Williams, 2006). These comorbidities have therefore led to the emergence of integrated community and healthcare approaches or more specifically the Integrated Management of Neonatal and Childhood Illness (IMNCI) approach to managing common childhood illness with the involvement of parents in providing home-based care, prevention of diseases through immunization, good nutrition and breastfeeding. The IMNCI was developed by the World Health Organization (WHO) as a comprehensive approach to delivering quality healthcare to sick children particularly in low-and-middle-income countries (Lawn, Kerber, Enweronu-Laryea & Cousens, 2010). The IMNCI comprises primarily of three components, namely improving overall health systems, improving case-management skills, and improving family and community health practices for both home care and health-care seeking for sick children (Lawn et al., 1 University of Ghana http://ugspace.ug.edu.gh 2010). It provides a comprehensive description of the management of common illnesses among infants and children. As at 2012, the IMNCI was present in more than 100 countries worldwide (Bhandari et al., 2012). About 44 of the 46 countries in sub-Saharan Africa are in various stages of IMNCI implementation (Lawn et al., 2010). Indeed, the IMNCI protocol has been implemented by countries across the world and has been found to be a more cost- effective and holistic way of managing neonatal and childhood illness with better health outcomes (Bryce, Gouws, et al., 2005; Gera, Shah, Garner, Richardson, & Sachdev, 2016; Zhang, Dai, & Zhang, 2007). Recent studies have indeed revealed the benefits of the IMNCI protocol in improving the quality of healthcare provided to children (Rakha et al., 2013). An evaluation of the IMNCI strategy in 12 countries over the world revealed that the training of healthcare workers improved the quality of care, reduced under-five mortality by about 13%, as well as increased utilisation of government health facilities over its two years implementation (Ahmed, Mitchell, & Hedt, 2010; Basaleem & Amin, 2011; Bhandari et al., 2012). Following the impact of this strategy on health utilization and outcome, it has since been implemented in over 100 countries across the world, including Ghana (WHO IMCI, 2014). Recent mortality rates for children under-fives in Ghana suggest 60 deaths per 1000 live births in 2014 (GDHS, 2014). This rate, though lower than previous ones in Ghana, is still too high according to the WHO’s target required to achieve the then 2 University of Ghana http://ugspace.ug.edu.gh Millennium Development Goal 4 (Liu et al., 2015). The global agenda for all countries is to reduce under-five mortality to at least 25 per 1000 live births by 2030 (WHO, 2017). In Ghana, numerous interventions have been implemented to respond to the global target of reducing under-five mortality to at least 25 per 1000 live births and to tackle the problem of high infant and child mortality rates. These include the Expanded Programme on Immunization, Exclusive breastfeeding, and peri partum continuum of care (Ministry of Health, 2010). Ghana also adopted the IMNCI as one of the key strategies for reducing mortality in children less than five years of age in 1998 (MOH, 2002). At the time of adopting this protocol, about 70% of deaths among children under five were due to acute respiratory infections (ARI), malaria, diarrhoea, measles, and malnutrition, and about 50% of these deaths occurred in the community (MOH, 2002). Hence, this protocol was aimed at training health workers to adopt a holistic approach to assessing sick children under five to identify co-morbidities instead of the single disease approach which was previously in use. The protocol was also designed to educate mothers of children under five years to utilise the existing health interventions such as immunisation, exclusive breastfeeding and also teach mothers on home management of sick children as well as improve health seeking behaviour (WHO, 2004). The IMNCI protocol has been implemented in Ghana for over a decade now and is currently being implemented across all health facilities in Ghana. Yet, the decline in under-five mortality is below the global expectation of 25 deaths per 100, 000 live birth. Following the launch of the protocol, health workers were to be trained to adopt it as the 3 University of Ghana http://ugspace.ug.edu.gh main strategy in managing illnesses of children under-five. However, the extent to which health workers are even aware of this protocol and adhere to its use in the management of childhood conditions is unknown. This study was therefore conducted to assess health workers’ knowledge and adherence to the use of the IMNCI protocol in the management of sick children. 1.2. Problem Statement Under-five mortality among children is one of the major public health problems plaguing the African continent. Most countries in Africa could not meet the Millennium Development Goal four of reducing child mortality by 75% by the year 2015 (United Nations, 2015). Although the WHO in collaboration with the United Nations International Children’s Emergency Fund (UNICEF) and other agencies, institutions and individuals developed the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) protocol with the aim of preventing, early detection and prompt treatment of leading childhood diseases, not much progress has been made in Africa (Batwala, Magnussen, & Nuwaha, 2011; Kiplagat, Musto, Mwizamholya, & Morona, 2014; Teferi, Teno, Ali, Alemu, & Bulto, 2014). The highest rates of child mortality are still recorded in sub-Saharan Africa where 1 in 9 children dies before age five, a rate which is more than 16 times the average for developed regions where 1 out of 152 children dies before age five (WHO/UNICEF/UN/World Bank, 2017). Similarly, the region has the highest risk of death among newborns and the most affected in neonatal mortality (Lawn, Kerber, Enweronu-Laryea, & Cousens, 2010). Five out of every ten deaths of children under five years of age in developing countries are from pneumonia and diarrhoea, which constitute 4 University of Ghana http://ugspace.ug.edu.gh the principal health problems of children, while malnutrition, malaria and measles cause an additional two out of ten deaths (UNICEF, 2014). Ghana, like many other countries in Africa, could not achieve MDG 4. Currently, one in every twelve children dies before their fifth birthday despite the country having implemented the IMNCI protocol since 1998 (UN/NDPC, 2015). Both community- related factors and failure of the healthcare system to appropriately manage illness among children under 5 have been reported to be responsible for high under-five mortalities in other countries (Vincent Batwala et al., 2011; Bhandari et al., 2012; Teferi et al., 2014) and in Ghana (Welaga et al., 2013). The WHO states that many sick children are not properly assessed and treated by healthcare providers and that their parents are poorly advised (WHO, 2015). Studies in Ghana on IMNCI have focused on specific aspects such as laboratory test (Febir et al., 2015), and management of malaria (Osei-Kwakye et al., 2013), with limited attention paid to assessing health workers’ knowledge and adherence to the three focal areas in the IMNCI strategy. Non-adherence to the three focal areas could result in delays in treating the multiple conditions that sick children often present with in health facilities (WHO, 1997a; Shewade et al., 2013). For example, a study in the Brong Ahafo Region of Ghana found that health workers were not adhering to the various examination of children such as performing a bacteriological test for malaria parasites, which is required in the IMNCI protocol because of increased workload (Febir et al., 2015). This lack of examination resulted in presumptive treatment for malaria which negatively affected malaria case management (Osei-Kwakye et al., 2013). 5 University of Ghana http://ugspace.ug.edu.gh Indeed, after years of its implementation, child mortality rate reduction eludes the country. Factors responsible for this are poorly understood and few studies have sought to research into it. In view of this, the study sought to assess adherence to the use of the Integrated Management of Childhood and Neonatal Illness (IMNCI) protocol among health workers caring for sick children under five years in health facilities in the Accra Metropolis. 1.3. Objectives of Study 1.3.1. General Objective The general objective of the study was to assess adherence to the use of the IMNCI protocol among health workers caring for children under five years in Ashiedu-Keteke and Ablekuma Sub metropolis in the Greater Accra Region. 1.3.2. Specific Objectives The specific objectives of the study were to: 1. Determine the level of knowledge on IMNCI among health workers attending to sick children under five years in Ashiedu-Keteke and Ablekuma Sub metros. 2. Determine the level of adherence to the use of the IMNCI protocol among health workers attending to sick children under five years in Ashiedu-Keteke and Ablekuma Sub metros. 3. Identify the factors associated with adherence to the use of the IMNCI protocol among health workers attending to sick children under five years in Ashiedu-Keteke and Ablekuma Sub metros. 6 University of Ghana http://ugspace.ug.edu.gh 1.4. Research Questions To address the specific objectives of the study involved answering the following research questions: 1. What is the level of knowledge on IMNCI among health workers attending to sick children under five years in Ashiedu-Keteke and Ablekuma Sub metros? 2. What is the level of adherence to the use of the IMNCI protocol among health workers attending to sick children under five years in Ashiedu-Keteke and Ablekuma Sub metros? 3. Which factors are associated with adherence to the use of the IMNCI protocol among health workers attending to sick children under five years in Ashiedu-Keteke and Ablekuma Sub metros? 1.5. Justification Many of the conditions that are responsible for the death of children such as malaria, acute respiratory tract infection, diarrhoeal diseases, and malnutrition are either preventable or can be treated with low-cost remedies at both community and health facility levels. Availing children to immunization and use of insecticide-treated bed nets can prevent some of these conditions (Pell, Straus, Andrew, Meñaca, & Pool, 2011). Nonetheless, evidence exists that Ghana still has high under-five mortality despite having implemented the IMNCI, which was purposively designed to ameliorate these deaths. Adherence to the use of the protocol could ensure the provision of good education to mothers to improve their child care and improve health-seeking behaviours to avoid delays that often result in complication and death among children under five (Chibwana, Mathanga, Chinkhumba, & Campbell, 2009; Källander et al., 2008). Therefore, information that would be obtained from this study could be used to improve on the 7 University of Ghana http://ugspace.ug.edu.gh quality of classification of childhood illness responsible for child mortality in Ghana. The factors responsible for non-adherence to the IMNCI protocol that would be identified in the study could also be used to improve the level of adherence among trained health workers. The information would also set the stage for modifying certain aspects of the IMNCI to improve detection and diagnosis of childhood illness in Ghana. The findings may also be useful in training of health workers on IMNCI. The barriers to adherence to the IMNCI protocol that would be identified in this study could be used to design intervention that can increase health workers’ adherence to the protocol which can positively improve quality of health care provided to children under-five years in Ghana. Other researchers may also use this information as a source of reference or literature in future research. 1.6. Chapter Summary This chapter provided a background to the study. The chapter particularly provided a description of the problem and why there is the need for conducting such a study in Ghana. The research objectives and questions were also outlined together with the justification for the study. The rest of the dissertation is organized as follows: Chapter 2 discusses the literature review, chapter 3 presents method. The fourth chapter is the results after data collected was analysed and the fifth chapter is a discussion of the results. The final chapter concludes with relevant recommendations. 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter reviews existing literature on factors associated with adherence to the use of the Integrated Management of Childhood Illness (IMNCI) protocol in the management of morbidities in children under five years. The review is guided by the objectives and the conceptual framework for the study. The review covers areas such as the burden of under-five mortality in the world, in Africa and in Ghana. It also provides literature on the various strategies that have been implemented over the years to improve the health of children under five years of age. This chapter also provides a detailed description of the IMNCI and its implementation strategies as well as the impact of IMNCI in reducing under-five mortality in the world. It finally narrows down the review to how the IMNCI have been implemented and the challenges in its implementation. The chapter also outlines and discusses a conceptual framework for the study. The chapter concludes by summarizing the gaps in the literature that this study seeks to address. 2.1. The burden of neonatal and childhood morbidity and mortality A neonate refers to an infant from birth to 28 weeks after birth. Hence neonatal mortality is the death of an infant within this period of life (Lawn et al., 2014). Morbidity and mortality of neonates and children under five years of age is a global burden. In New Zealand, a study found that the annual cost to Government of pneumococcal disease and otitis media admissions for children was $NZ 9.95 million, which is about $US7.1 9 University of Ghana http://ugspace.ug.edu.gh million (Milne & Vander Hoorn, 2010). Estimates of hospitalization for acute lower respiratory tract infection (ALRI) in children were responsible for almost 12 million hospitalizations in 2010 globally (Nair et al., 2013). In another study, it was found that the mean provider costs per patient for treating outpatient pneumonia, inpatient pneumonia, pneumococcal sepsis and meningitis among children under-five were US$8, US$64, US$87 and US$124 respectively in the Gambia despite the fact that these conditions are preventable (Usuf et al., 2016). In India, it has been reported that one in every 169 children will be hospitalized because of preventable conditions (Sarkar et al., 2014). In Ghana, malaria is responsible for the majority of childhood admissions and 22% of childhood deaths, while pneumonia is also responsible for about 22% of hospital admissions in tertiary health facilities (Abdul-Aziz et al., 2012).There have however been no current studies on the cost of hospitalization of children under five years of age in the country. Neonatal and childhood mortality is also reported to be a burden globally (Lawn et al., 2014). In 2015, 5.9 million children under five years were reported to have died, and this translated into about 16,000 children dying per day (UNICEF/WHO/World Bank, 2017). About 2.7 million (45%) of these deaths that occurred in 2015 were among newborns (WHO/UNICEF/UN/World Bank, 2016). There are regional variations in these deaths, however. Sub-Saharan Africa is reported to have the highest burden of under-five mortality (UNICEF/WHO/World Bank, 2017). It has been reported that 1 out of 12 10 University of Ghana http://ugspace.ug.edu.gh children in sub-Saharan Africa dies before attaining five years as compared to 1 out of 47 children in high-income countries (WHO/UNICEF/UN/World Bank, 2016). Studies have also shown that in low-resource countries, even when deliveries have taken place in health facilities, most newborns die at home and some may not even be reported partly because of early discharge and poor healthcare seeking behaviours (Wright, Mathieson, Lara Brearley, Jacobs, & Ravi, 2014). This, therefore, makes this period very critical in health interventions as the causes of such mortalities are largely preventable as indicated in the Ghana National Newborn Health Strategic and Action Plan 2014-2018 (MoH, 2014). 2.2. Strategies for reducing neonatal and childhood morbidity and mortality 2.2.1 Expanded Programme on Immunization of Children Under-five Years The Expanded Programme on Immunization (EPI) was launched in 1987 with six antigens - Oral Polio, Measles, diphtheria-pertussis-tetanus (DPT) and Bacillus Calmette- Guerin (BCG) for children under one year and tetanol toxoid (TT) for pregnant women. These vaccines were introduced to reduce morbidity and mortality of vaccine-preventable diseases through outreach, static and campaign strategies (Keja, Chan, Hayden, & Henderson, 1988). Immunization is one of the ways of preventing diseases especially among children and has contributed to the reduction of childhood diseases. It is also one of the important basic health services for all children (Mashal, Nakamura, Kizuki, Seino, & Takano, 2007). The introduction of vaccines has led to the reduction of many infectious diseases 11 University of Ghana http://ugspace.ug.edu.gh and most of the vaccines that prevent diseases in children are very effective and safe (Ada, 2007). Several of these vaccines are developed against bacteria, viruses and some parasites and new methods and techniques for developing more effective vaccines are becoming available (Ada, 2007). When many individuals are vaccinated, there can be protection for all through a process known as herd immunity (Finn & Savulescu, 2011). Developing countries contribute about 95% of the deaths in children under five years globally, and 70% of these deaths can be prevented by immunization (Mashal et al., 2007). For instance, good coverage of the early antigens following their introduction contributed to a significant decline in the incidence of most childhood killer diseases in Ghana (GHS, 2015a). The success of the antigens in reducing disease and mortality burden provided enough evidence to further introduce new vaccines to cater for other diseases. Based on the burden of some diseases and the possible opportunity to avert high infant deaths as well as economic benefits, Ghana began processes to introduce the pneumococcal and rotavirus vaccines as well as a second dose of measles in 2009 (GHS, 2014). Immunization activities are ongoing throughout the 216 districts in Ghana as envisioned in the EPI protocol. The Ghana Health Service in 2015 reported that the supply of all the antigens for infant immunization is often regular with minimal cases of shortage reported across the countries (GHS, 2015). Out of the 216 districts in Ghana, 150 districts (69.7%) have recorded penta3 coverage ≥ 80% while two districts recorded penta3 coverage of <50% (GHS, 2015). 12 University of Ghana http://ugspace.ug.edu.gh 2.2.2 Early Initiation of Breastfeeding and Exclusive Breastfeeding Infant and young child feeding is critical for child health and survival. The WHO and UNICEF recommends that mothers put newborns to the breast within one hour of birth, breastfeed infants exclusively for the first six months and continue to breastfeed for two years and beyond, together with nutritionally adequate, safe, age-appropriate, responsive feeding of solid, semi-solid and soft foods starting in the sixth month (UNICEF, 2015). Exclusive breastfeeding is the best infant feeding practice compared to other breastfeeding practices such as predominant breastfeeding and complementary feeding (Edmond et al., 2006). It involves feeding a child with no other food or drink, not even water except breast milk (including expressed milk or from a wet nurse) for six months but allows intake of ORS and prescribed medications (Edmond et al., 2006). It is recommended as the best feeding alternative for infants up to six months, as it has a protective effect against morbidity and mortality (Ogbonna & Daboer, 2007). It also lowers HIV-1 transmission compared to mix feeding (Ogbonna & Daboer, 2007). 2.2.3 Continuum of care The concept of a continuum of care has received global attention in recent times. Continuum of care encapsulates a broad spectrum of care along reproductive, maternal, newborn and child health with linkage of service outlets and delivery approaches (Kerber et al., 2007). This concept refers to a system that integrates and emphasizes the continuity of care from pre-pregnancy, pregnancy, birth, and after delivery (AbouZahr & Berer, 2000). This continuum of care is critical for both maternal and child health and therefore plays an important role in reducing both maternal and child mortalities (AbouZahr & Berer, 2000; Kerber et al., 2007). 13 University of Ghana http://ugspace.ug.edu.gh Continuum of care has also received prominence in the newly adopted sustainable development goals. The Global Agenda and Strategy for Children, Adolescents and Women health as captured in the sustainable development goals (2016-2030) aims at positioning discussions on maternal mortality issues within a continuum framework of programmes to improve maternal and child health globally (WHO, 2016a). The clinical care component looks at the reproductive health, childbirth care and newborn baby and child care. According to Lawn, Zupan, Begkoyian & Knippenberg (2006), the reproductive health component’s emphasis is on case management for sexually transmitted infections (STIs), elective abortion where legal, emergency care and post- abortion care. However, the childbirth care looks at skilled obstetric care at birth and essential neonate care (hygiene, warmth, breastfeed) and resuscitation, prevention of mother to child transmission of HIV and emergency obstetric care as well as immediate emergency care for newborn babies. The final component includes interventions such as emergency care for newborn babies, case management of childhood and neonatal illness, extra care for preterm babies, including Kangaroo mother care and care of children with HIV. The second component, which looks at the outpatient care and outreach services is further categorized into four groups namely; reproductive health, antenatal care (ANC), postnatal care (PNC) and child health (Lawn, Cousens, & Darmstadt, 2005). The reproductive group includes interventions such as family planning, elective abortion where legal, prevention and management of sexually transmitted infections and HIV and folic acid and iron supplementation (Lawn, Cousens, & Darmstadt, 2005). The ANC group 14 University of Ghana http://ugspace.ug.edu.gh includes measures to ensure four to eight focused ANC visits package that is integrated with malaria prevention, intermittent preventive treatment in pregnancy (IPT), and insecticide-treated bed nets, tetanus immunization, and prevention of maternal to child transmission of HIV (WHO, 2016b). However, the PNC component looks at the promotion of healthy behaviours for mother and baby, early detection and referral of complications, extra visits for preterm babies, prevention of maternal to child transmission of HIV, including appropriate feeding and family planning services (Byrom, Edwards, & Bick, 2009). The final component (child health) under this category involves vaccinations of children, malaria prevention using insecticide-treated bed nets, child nutrition, including vitamin A and zinc supplementation, care of children with HIV, including co-trimoxazole and integrated management of neonatal and childhood illness (IMNCI) (Lawn, Cousens, & Darmstadt, 2005). Finally, the family and community care component of continuum of care involves interventions such as adolescent and pre-pregnancy nutrition, including use of iodised salt, health education, prevention of HIV and STIs, healthy home behaviours for women in pregnancy such as reduction of workload, recognition of danger signs, emergency preparedness, community behaviours, emergency transport, and funding schemes (Lawn et al., 2006). This component also involves skilled care, education about clean delivery, and simple early care for neonates, including warmth and immediate breastfeeding. It also involves water, sanitation, and hygiene, promotion of demand for quality skilled care, recognition of danger signs, and care-seeking, case management of diarrhoea with 15 University of Ghana http://ugspace.ug.edu.gh oral rehydration salts, and, where use of facility care is low, case management of pneumonia, severe malnutrition, neonatal sepsis, and malaria (Lawn et al., 2005, 2006). 2.2.4 Integrated Community Case Management of Childhood Illness (ICCM) The ICCM was developed by the WHO to reduce the burden of diarrhoea, malaria and pneumonia among children under five years of age (WHO, 1997b). The goal of the iCCM strategy was to reduce childhood morbidity, and mortality by providing case management for malaria, pneumonia, and diarrhoea to sick children within their communities as well as identifying and referring sick newborn babies (WHO/UNICEF, 2011). A review of countries that implemented the ICCM protocol showed that it has reduced 70% of childhood pneumonia-related mortality among children under-five years of age (Theodoratou et al., 2010). Community case management (CCM) of malaria was also found to reduce overall and malaria-specific under-five mortality by 40% and 60%, respectively, and severe malaria morbidity by 53% (Kidane & Morrow, 2000; Sirima et al., 2003). In Malawi, the iCCM protocol was found to have improved management of childhood illness (Nsona et al., 2012). In Uganda, it was found that the number of children receiving community-based treatment for diarrhoea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000, which also resulted in decline in under-five mortality by 38% (Mugeni et al., 2014). The current guidelines for the integrated community case management (iCCM) of childhood illness require that Community Health Workers (CHWs) treat febrile children without danger signs who have diarrhoea, pneumonia (cough/difficulty breathing and fast 16 University of Ghana http://ugspace.ug.edu.gh breathing), or malaria at the community level, and refer any child with danger signs to an appropriate health facility (Crump et al., 2013; D’Acremont, Lengeler, & Genton, 2010; Hertz, Munishi, Sharp, Reddy, & Crump, 2013; World Health Organization, 2013). Parents or Guardians of children treated at the community level are counseled to return in three days to assess treatment compliance and illness resolution. Those children without a diagnosable illness and without danger signs are also told to return to the CHW in three days, per WHO ICCM guidelines (WHO / UNICEF, 2011). 2.3. The IMNCI and its Components As noted earlier, the IMNCI was developed by the WHO as a comprehensive approach to delivering quality healthcare to sick children particularly in low-and-middle-income countries (Lawn & Knippenberg, 2006). The IMNCI has three components (see figure 1): improving case-management skills of health workers, improving health systems support, and improving family and community practices, also called the community and family practices of IMNCI (C-IMNCI) (Kenya-Mogisha & Pangu, 1999). The three components of the IMNCI strategy are most effective when they are implemented simultaneously. 17 University of Ghana http://ugspace.ug.edu.gh Figure 1: Integrated Three Components of IMNCI protocol (Source: WHO, 2003) The case management guidelines of the IMNCI use algorithms of specific signs and symptoms that children present and how the knowledge on these signs are translated into the classification of the condition (WHO, 2003). The patient’s condition is classified and recommended treatment administered, including treatment administered at the clinic before hospital referral (pre-referral treatment) (Gove, 1997). The signs and symptoms in the IMNCI protocol include a cough and cough-related signs, diarrhoea, fever and ear problems (WHO, 2003). 18 University of Ghana http://ugspace.ug.edu.gh The other health system interventions involve vaccinations, micronutrient supplementation, health worker counselling for breastfeeding and appropriate complementary feeding (WHO, 2006). These also form the preventive level interventions of the health system. The curative component involves case management of acute respiratory infection, diarrhoea, measles, malaria, malnutrition, and other serious infections, counselling on feeding problems, iron for treatment of anaemia and anti- helminthic treatment for worm infestations among children under five years (WHO, 2006). Community-level IMNCI is important in good child care, health seeking, and treatment outcome. This is done through education of mother and caretakers of children under-five years on exclusive breastfeeding, appropriate infant feeding practices, peer counselling for breastfeeding and complementary feeding, use of long-lasting insecticide treated bed nets and appropriate infection control practices (Maheshwari, Kumar, & Dutta, 2012; Shewade et al., 2013). These form the preventive aspect of community-level interventions. The second component of the community is related to response to illness, and these involve early recognition and home management of illness, appropriate care seeking and adherence to treatment recommendations (WHO, 2006). 2.4. Impact of IMNCI Findings on the impact of IMNCI have been mixed. Whereas some studies have demonstrated the positive impact of IMNCI on health indicators, other studies found no difference. In Egypt, it was found that implementation has resulted in the average annual decline of under-five mortality by 6.3% in 127 districts, with some district recording up 19 University of Ghana http://ugspace.ug.edu.gh to 7.3% after IMNCI implementation (Rakha et al., 2013). In Brazil and Peru, it emerged that the implementation of IMNCI in health facilities did not show any impact on mortality though implementation was generally described as weak in those countries (Bryce, Victora, et al., 2005; Victora et al., 2005). A study in Tanzania found that IMNCI was able to reduce under-five mortality by 13% in a district that implemented the protocol (Armstrong Schellenberg et al., 2004). Community-based IMNCI has also been found to be effective in improving the health of children under five years. A study in Uganda found that caretakers’ lack of knowledge of C-IMNCI increased the odds of wasting by 4.5 times and stunting by 1.7 times (Mukunya et al., 2014). 2.5. Knowledge and attitude to IMNCI in management of children under five years A study among health workers in Tanzania found that 69% of trained healthcare workers expressed understanding of the IMNCI approach, with 77% having a positive attitude towards its implementation (Kiplagat et al., 2014). A study among nurses in India found that 62% has adequate knowledge, 32% had the moderate knowledge and 6% had inadequate knowledge on assessment, classification and treatment aspect of the IMNCI protocol (Danasu, Ananadhy, & Kumudhavalli, 2016). In terms of attitude, 76% had a good attitude, 24% had a poor attitude and none of them had a very poor attitude (Danasu et al., 2016). According to one study, 51.4% of workers providing care to children under five had adequate knowledge (Khan, Khowaja, & Ali, 2012), while another study in Pakistan found that 58% of healthcare workers were deficient in their knowledge on the clinical management of childhood illnesses ( Khan, 2009). 20 University of Ghana http://ugspace.ug.edu.gh 2.6. Adherence to the IMNCI protocol in the management of children under five years Studies on adherence to the use of various components of the IMNCI have produced different levels of adherence. In a multi-country survey, it was found that only 18% of health workers checked for all main symptoms of children as required by the protocol (Goga et al., 2009). In South Africa, less than 2% of healthcare workers (HCWs) referred to the IMNCI guidelines; 12% of IMNCI trained HCWs were found to check general danger signs in every child; and 18% assessed all the main symptoms in every child (Ahmed et al., 2010). As a result, less than half of the children with severe classifications were correctly identified (Ahmed et al., 2010). Again, in Tshwane in South Africa, it was found that health workers were not adhering to the IMNCI guide for managing children under five years as only 52.9% adhered to the IMNCI classification of illness (Mulaudzi, 2015). In Uganda, similar findings were reported (Batwala, Magnussen, & Nuwaha, 2011). Furthermore, in Egypt, it was found that adherence to disease classification was 100%, assessment for jaundice (100%), bacterial infection (95%) and 84.7% for weight assessment (El-Ayady, Meleis, Ahmed, & Ismaiel, 2015). The findings of a study conducted in Botswana also revealed that most of the HCWs managed sick children aged five years and younger but only 45% used the entire IMNCI strategy (Mupara & Lubbe, 2016). 2.7 Factors influencing IMNCI adherence The United Nations International Children’s Emergency Fund (2016), through a study conducted in 2016 outlined some key factors which affected IMNCI implementation. Key among their findings was the supervision of healthcare workers. They further noted that the 21 University of Ghana http://ugspace.ug.edu.gh provision of proper training for healthcare workers, equipping them with the requisite tools and materials could substantially reduce child deaths (United Nations Children’s Fund (UNICEF)., 2016). In a similar vein, The Ifakara Health Institute in Tanzania carried out a qualitative research to investigate the process of IMCI implementation. In this study, they selected a district that was performing creditably and one that was not performing well to explore the experiences of these districts as well as the facilities. From their study, low training coverage was highlighted as posing a serious threat to IMNCI adherence. It was further found that duration of the protocol, poor supervision, reluctance to refer, lack of job aids and IMNCI drugs were key reasons given for the poor adherence to the protocol (Borghi & Prosper, 2009). Izudi, Anyigu, and Ndungutse (2017) investigated the factors linked with adherence to IMCI protocol in Aweil East County of South Sudan. From their study, academic qualifications were significantly related to adherence. Persons who had higher academic qualifications adhered more to the protocol. They also identified guideline complexities with regard to the time or duration to be significantly related to adherence. Availability of drugs for IMNCI were the associated factor. 22 University of Ghana http://ugspace.ug.edu.gh 2.8 Conceptual Framework Health systems ❖ Designated Area ❖ Protocol Socio-demographic ❖ Training on IMNCI Characteristic ❖ Health Facility ❖ Professional ❖ Logistics/supplies qualification Adherence ❖ Number of years to IMNCI of work Protocol ❖ Age Health workers knowledge/skill/Practices ❖ Marital Status ❖ Assessment ❖ Religion ❖ Classification ❖ Treatment and Management ❖ Years of work experience ❖ Education and counselling ❖ ❖ Education and counselling Figure 2: Conceptual framework illustrating factors that may influence adherence to the use of IMNCI Protocol 23 University of Ghana http://ugspace.ug.edu.gh Figure 2 illustrates the conceptual framework of this study. It is based on the literature reviewed above, which showed that the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) is a strategy that was adopted in the health delivery system specifically to child health using guidelines designed for the management of sick children from birth up to five years old. Its implementation largely depends on health workers’ skill as well as improved health systems. The health worker should be skillful enough to identify the signs and symptoms of illnesses in sick children so as to assess, classify appropriately and be able to manage the sick child. Designated Area, Availability of Protocols, Training on IMNCI, Logistics/supplies are some of the factors under health systems which could affect adherence. The health worker, given all the needed logistics and training, should be able to adhere to the steps in the protocol of the IMNCI which include education and counselling on immunization and breastfeeding, proper classification, and referral if need be 2.9 Chapter Summary From the literature review, it is clear that several interventions exist to reduce morbidity and mortality among children under five years of age. The IMNCI protocol was also developed to sensitize health workers on the need to use an integrated approach in assessing sick children who report to health facilities. This was a shift in protocol from the single disease approach which was used to diagnose and treat children. Despite the fact that studies have shown that the protocol has a positive impact on improving child health in other countries, few studies have been done on the impact of the protocol in Ghana. Also, no study in Ghana has assessed health worker knowledge about this protocol and their level of adherence to using the protocol in assessing, classifying and 24 University of Ghana http://ugspace.ug.edu.gh managing sick children. Studies in Ghana that relate to IMNCI had to do with adherence to test before treat protocol for malaria. However, the IMNCI protocol is integrated and goes beyond assessing for only malaria but comprehensive history that could lead to treating co-morbidities such as malaria, dehydration, diarrhoea and pneumonia disease. This study was therefore designed to fill these gap in literature by assessing healthcare workers’ knowledge and adherence to the IMNCI protocol in Ghana. 25 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.0. Introduction This chapter discusses the methods used in addressing the research questions. The chapter describes the study design, setting, population, sample size calculation and sampling, data collection tool and procedures. It also presents how data obtained was analyzed as well as data management strategy. Finally, it presents how ethical issues were handled in the study. 3.1. Study design This study was a cross-sectional study using a quantitative approach. A cross-sectional study is a type of research in which a subset of the population is selected, and from these individuals, data are collected to help answer research questions of interest and the data is collected at one point in time (Oslen & Marie, 2004). A quantitative research approach is used when a researcher wants to create meaning through objective measurement of the situation and presents the findings of the study numerically (Williams, 2007). The quantitative approach was deemed more appropriate as it made it possible for the researcher to sample a cross-section of health workers to participate in this study where the level of knowledge and adherence to IMNCI protocol were assessed and the findings used to infer the situation across health workers in the study area. 26 University of Ghana http://ugspace.ug.edu.gh 3.2 Study area The Accra Metropolitan Assembly under the Regional Health Directorate is divided into 6 sub-metros, namely Ablekuma, Ashiedu-Keteke, Ayawaso, Kpeshie, Okaikoi, and Osu- Clottey. The names of these six sub-metros were written and put in a bowl and two were randomly selected to serve as the study areas. The Ablekuma and Ashiedu-Keteke were picked and these served as the study areas. The study was conducted in Princess Marie Louis Hospital and Ussher Polyclinic in the Ashiedu-Keteke sub-metro as well as Mamprobi and Dansoman polyclinics in the Ablekuma sub-metro. Apart from Korle-Bu Teaching Hospital, these are the public health facilities in the two selected sub-metros. The Greater Accra region is the smallest region in Ghana, but with the highest number of health workers in the country across all professional categories (MoH, 2011). In the year 2015, the Greater Accra region had 1,468 doctors, 6, 524 nurses, 973 midwives and 204 pharmacists (GHS, 2016). Also, the population distribution shows that Greater Accra region has the highest proportion (11.7%) of the 0-4 year age group in Ghana, which forms the critical group for this research (GSS, 2013). These factors make the region an ideal study area for the present study. Healthcare provision in the metropolis is organized at three levels; primary, secondary and tertiary (GHS, 2015b). The primary healthcare facilities are those located in the district and sub-district level and provide essential healthcare. Secondary healthcare provision is usually based in a hospital or clinic and caters to clients referred from the primary healthcare facilities. The health facilities selected for this study fall into this 27 University of Ghana http://ugspace.ug.edu.gh category of healthcare services. The tertiary healthcare facilities are largely tertiary hospitals, referral centers, where healthcare is provided by specialists. 3.3 Study population The study population were doctors and nurses, working in children wards and taking care of sick children at the four public health facilities located within the two sub-metropolis. The work of these people involves taking care of sick children under-five years of age since the IMNCI specifically targets this cadre of health workers. 3.3.1 Inclusion criteria All doctors and nurses who care for sick children under five years in the study facilities were included. 3.3.2. Exclusion criteria: Doctors and nurses who were directly involved in the care of children under 5 years but were not present during the time of data collection were excluded from the study. Participants who also failed to give their consent were not included in the study. 3.4 Determination of sample size The sample size for this study was computed using Cochran formula for population proportions in a cross-sectional survey (Cochran, 1977). Where n= the minimum sample size 28 University of Ghana http://ugspace.ug.edu.gh Z is the standard normal variate for population distribution. In this study, a 95% confidence interval was used. Therefore, a 5% type 1 error was allowed and the level of significance placed at p <0.05. At p<0.05, Z =1.96. p= Adherence to IMNCI protocol. A study in Egypt found that the highest adherence to IMNCI was 94% whilst the least was 56.2% (El-Ayady et al., 2015). Based on this an average of 75.1% was computed. Hence, p=0.751 d=margin of error (0.05) Hence, n=287. A 5% non-response rate (14) was added to the minimum sample size leading to 301 health workers as the final sample size. 3.5. Sampling Procedure The Public Health facilities in the two sub-metros were purposively chosen based on service provision for sick children under five. In this regard, the study was conducted in Princess Marie Louis Children Hospital (PML) and Ussher Polyclinic in the Ashiedu- Keteke sub-metro as well as Mamprobi and Dansoman Polyclinics in Ablekuma sub- metro. Apart from Korle-Bu Teaching Hospital, these are the public health facilities in the two sub-metros of the Greater Accra Region of Ghana. A multistage sampling procedure was however followed to recruit individual respondents into the study. Using the register of all doctors and nurses caring for sick children in the four facilities at the time of collecting the data, the ratio of doctors to nurses was found to 29 University of Ghana http://ugspace.ug.edu.gh be 6:211 at the Mamprobi Polyclinic, 10:72 at the Ussher Polyclinic, 23:133 at the PML Hospital and 6: 62 at the Dansoman Polyclinic totaling 478, and comprising 45 doctors and 433 nurses. With a required sample size of 301, a simple proportionate sampling technique was used to allocate the sample size of 301 to the four health facilities. This ensured that health facilities with larger numbers of healthcare providers got the largest sample. In all, 126 healthcare providers were recruited from Mamprobi Polyclinic, 92 from PML Children’s Hospital, 46 from Ussher Polyclinic and 36 from Dansoman Polyclinic. The total number of questionnaires returned from the facilities was 300. A list of all doctors and nurses who worked with children under five years within the duration of data collection was gotten from the health administration unit of each of the selected health facility. Numbers were assigned to each staff and a simple random sampling was done using an electronic random number generator software to recruit the required number of staff from each facility. All randomly selected staff were contacted on days they were on duty, whereby the study and sampling procedures were explained. Where the respondent agreed to take part in the study, interviews were either conducted the same day or questionnaires were given out for self-administration. For such respondents, arrangements were made to retrieve completed questionnaires at a later date or time. 30 University of Ghana http://ugspace.ug.edu.gh 3.6. Data Collection Methods and Tools Data was collected through a survey. A structured questionnaire was designed for the data collection. The questionnaire was divided into different sections. Section A of the questionnaire collected data on the socio-demographic and professional background of the respondents. Section B elicited information on the participant’s knowledge about the various components of the IMNCI protocol. Section C of the questionnaire elicited information on adherence or use of the IMNCI in attending to sick children under five years of age. The information elicited in this section centered on IMNCI clinical symptoms and signs, classification and education of mothers. Section D of the questionnaire also elicited information on health facilities’ equipment, supplies and medication relevant to IMNCI. The questionnaire was adapted from the WHO health facility survey tool (Appendix A), (WHO, 2003). The data was collected among doctors and nurses who provide care for children under five at the Mamprobi polyclinic, USHER polyclinic, Princess Marie Louis Children Hospital and the Dansoman polyclinic from 4th June to 29th June 2018. Each participant was engaged for approximately 20 to 30 minutes, within which period the data was collected. The questionnaire was self-administered. 31 University of Ghana http://ugspace.ug.edu.gh 3.7 Pretest of Data Collection Instrument The questionnaire was pre-tested at Kaneshie Polyclinic. A sample of 20 respondents (17nurses, 3 doctors) were recruited for the pretest. The data from the pretest was entered into Stata version 15 for analysis. A Cronbach Alpha index was computed to test the reliability of this measurement tool and a coefficient of 0.67 was gotten implying the data collection tool was reliable (Streiner & Norman, 2008) 3.8. Quality assurance As part of quality assurance, a pretest of the tool was done as stated earlier and the reliability index of the tool computed. The principal investigator with two trained personnel administered all the questionnaires. The completed questionnaire was reviewed for completeness. Double data entry was done and the two entries compared for correction. Where there were differences, the main questionnaire was reviewed in order to make the needed correction 3.9. Variables Table 1: Description of dependent variable of interest Variable Operational definition Scale of measurement Adherence Health workers assessing, classifying, treating child Binary and counseling caregiver as recommended by IMNCI to IMNCI guidelines (High or Low) protocol High (above average score on health worker usage) Low (average or lower score on health worker usage) 32 University of Ghana http://ugspace.ug.edu.gh Table 2: Description of independent variables of interest Variable Operational definition Scale of measurement Age Age at last birthday of health worker (in years) Numeric (Discrete) Binary Sex Gender of health worker Female or Male Professional Professional capacity in which health worker is Categorical qualification employed (Nominal) Duration of The number of years a health worker has worked at Categorical (Nominal) work their current health facility The religious belief health worker identifies best Categorical Religion with (Nominal) Marital status The current spousal relationship of health worker Categorical (Nominal) Health worker’s knowledge on IMNCI High Binary (High or Low) (above average score on health worker’s Level of knowledge) knowledge Low (average or lower score on health worker’s knowledge) Whether facility was supervised or not at least once Binary (Yes or No) Supervision in the last 3 months The availability of relevant medicines in stock at Binary the pharmacy unit on the day of data collection. (High or Low) Availability of High (90% or more of the relevant medicines medicines available in stock) Low (Less than 90% of relevant medicines available in stock) Whether the health facility has a room or place Binary Designated allocated for IMNCI or not IMNCI corner (Yes or No) 33 University of Ghana http://ugspace.ug.edu.gh 3.10. Data analysis The completed questionnaire was entered into Microsoft Excel. The data was then imported into Stata version 15.0 for analysis. Knowledge and adherence of respondents were measured at two levels. At first, an individual’s knowledge and adherence were measured at specific dimensions of the questionnaire on assessment, classification, treatments, and education. Bowling (2014) is of the view that just reporting aggregated/weighted average scores have the tendency to mask the nuances available in any data to help address some specific intervention points. After the analysis at the individual variable levels, a median was computed for each category of response: assessment, classification, treatments, and education. The questionnaire items related to knowledge were recoded 1 (for chosen responses that corresponded to answers known in the IMNCI protocol and literature) or 0 (for responses which vary from answers known in the IMNCI protocol and literature). The item scores were summed to obtain composite scores after which the median composite score was used to re-categorise knowledge as low or high. Low knowledge corresponded to composite scores which were equal to or less than the median composite score and high knowledge corresponded to composite scores which were above the median composite score. A similar procedure was used to categorise adherence as being low or high. The composite scores for adherence were obtained by summing the individual scores on each item. Respondents who scored above the average were classified as having high adherence while those whose score fell within the median and below were classified as having low adherence in each category. Wherever characteristics related to measuring 34 University of Ghana http://ugspace.ug.edu.gh adherence were described as accurate or inaccurate it referred to responses which were consistent or varied, respectively, with answers to questionnaire items which are clearly established in the IMNCI protocol. Similarly, when respondents’ description of their classification departed from the recommendations of the IMNCI protocol it was described as “wrong” classification. Descriptive statistics were generated for each variable to show the proportions. Descriptive statistics were also used to present the proportions on background characteristics of the respondents at the univariate level. This was followed by a bivariate analysis using Chi-square test. Pearson’s chi-square test of independence was performed to test for individual independent association between the independent and dependent variables with observations more than six. This is because Pearson’s Chi-square has been reported to demonstrate more stability and gives a better estimator for such type of variables (Camilli, 1995). However, for variables with observations less than six, which are also nominal and dichotomized, a Fisher's exact test was used to determine the associations (Routledge, 2005). A logistic regression analysis was then performed at two levels. The first aimed to establish the crude level of strength of association between the independent variables (e.g. socio-demographic and professional background) and the dependent variable for categorical variables (adherence to IMNCI). Afterward, a multivariable logistic regression model was fitted to adjust for the effects of other variables. A p-value of less than 0.05 was deemed to be statistically significant at a confidence level of 95%. 35 University of Ghana http://ugspace.ug.edu.gh 3.11. Ethical consideration The proposal for this study was submitted to the Ethical Review Committee of the Ghana Health Service for approval (see appendix III). Prior to sampling and data collection, permission was sought from the administration of the various health facilities to be used in the study. A letter of introduction from the School of Public Health introducing the researcher was sent to all selected health facilities. Permission was granted by all the facilities before commencement (Appendix III). Participants in this study were informed about the objectives of the study. They were also informed that participation in this study was voluntary. All the questions participants asked were addressed and they signed a consent form before participating in the study. All selected participants were informed of their right to withdraw from the study at any time after agreeing to participate without suffering any negative consequence. They were also informed that they had the right to decline any question to which they were unwilling to respond. Participants were told that there were no risks and benefits in participating in this study. However, the findings of the study may inform protocol, which may indirectly benefit participants. All data collected were kept as confidential. Personal identifiers of participants were not collected, and people unrelated to the study will have no access to the study’s data. Findings of the study were reported in aggregates. Hence it would be impossible for anyone to trace a particular response to a respondent. 36 University of Ghana http://ugspace.ug.edu.gh 3.12. Chapter Summary This chapter discussed the methods used to carry out the study. It comprised of the study design, the study area, study population, sampling method, data collection, and analysis as well as ethical consideration. The next chapter presents the results. 37 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the results of the study. The results focus on the socio-demographic characteristics of respondents, knowledge of, and adherence to, the IMNCI protocol, and factors associated with adherence. 4.1 Socio-demographic characteristics of respondents A total of 301 questionnaires were sent out and 300 were completed and returned, yielding a response rate of 99.7%. Background characteristics of respondents have been summarised in Table 3. The age of respondents ranged from 20 to 50 years. The proportion of respondents who were males was 11.7% (35 out of 299). Majority of respondents (88.3%) were in the nursing/midwifery category. The predominant religion of respondents was Christianity (94.7%). Of the 300 respondents, 54% work within the Ablekuma sub-metro (42% at Mamprobi Polyclinic and 12% at Dansoman Polyclinic), while 46% work within the Ashiedu-Keteke sub-metro (30.7% at the Princess Marie Louis Children hospital and 15.3% at the Ussher polyclinic). Approximately 60% of respondents have been working at their current health facilities for 3 years or less (20% for less than 1 year and 39.7% for 1 to 3 years). 38 University of Ghana http://ugspace.ug.edu.gh Table 3: Socio-demographic characteristics of respondents Variable Median (IQR) Frequency(N=300) Percent Age (years) 30 (28 - 34) 18 – 29 years 123 41.0 30 – 39 years 158 52.7 ≥ 40 years 19 6.3 Sex (n= 299) Female 264 88.3 Male 35 11.7 Marital Status (n=300) Single 169 56.3 Married 124 41.3 Divorced 5 1.7 Cohabiting 2 0.7 Religion (n=300) Christianity 284 94.7 Islam 15 5.0 Traditional African religion 1 0.3 Professional category (n=300) Community Health Nurse 71 23.7 Midwife 54 18.0 Registered General Nurse Diploma 111 37.0 Degree Nurse 29 9.7 Medical Doctor 29 9.7 Health Facilities (n=300) Princess Marie Louis Hospital 92 30.7 Ussher Polyclinic 46 15.3 Mamprobi Polyclinic 126 42.0 Dansoman Polyclinic 36 12.0 Working duration at Facility (n=300) Less than 1 year 60 20.0 1 - 3 years 119 39.7 4 - 5 years 85 28.3 More than 5 years 36 12.0 4.2 Awareness and Training on IMNCI The proportion of respondents who had never heard of the IMNCI protocol was 18.7% (56 out 300). Of these, 39.3% (22 out of 56) were registered general nurses (diploma) and 39 University of Ghana http://ugspace.ug.edu.gh 30.4% (17 out of 56) were community Health Nurses. Of all the medical doctors, 10.3% (3 out of 29) had never heard of IMNCI while all 6 Physician Assistants had heard of it. Figure 4 also shows the proportions of respondents who have been trained or never been trained on the IMNCI protocol. A little over half of the respondents (57.6%) had been trained on IMNCI. Of the 57.6% respondents trained on IMNCI who indicated the number of times they had been trained, only 14.6% had been trained more than once. While 54.1% of professionals in the nursing category had been trained, 82.9% of doctors and physician assistants had been trained. Regarding training received among the different age categories, 77.8% those aged above 40 years had been trained while 49.2% of those aged 18 to 29 years had been trained and 61.7% of those aged 30 to 40 years had been trained. While a lot of respondents were able to accurately identify IMNCI as “Integrated Management of Neonatal and Childhood Illnesses” other descriptions given included “protocol for children who are sick”, “protocol for under five”, “Integrated management of Neonatal of Childhood Illnesses”. 40 University of Ghana http://ugspace.ug.edu.gh 57.6 42.4 Never trained Trained Figure 3: Percentage distribution of respondents by training on the IMNCI protocol 4.3 Knowledge on IMNCI components Table 4 shows the proportion of respondents who gave accurate and inaccurate answers to questions asked to assess knowledge on components of the IMNCI protocol. While a little over half of the respondents (52.3%) rightly knew that a component of IMNCI was to improve health workers’ skills, 60.7% wrongly thought that a component of IMNCI was to improve appropriate use of charts for child care, 37% wrongly conceived a component of IMNCI as being to improve uptake of family planning, and 55.7% wrongly thought another IMNCI component was to improve child safety. 41 percent 20 40 60 0 University of Ghana http://ugspace.ug.edu.gh Table 4: Knowledge on IMNCI components Knowledge of IMNCI components Responses (n=300) Accurate Inaccurate What are the various components involved in IMNCI? Improve health workers’ skills 157 (52.3) 143 (47.7) Improve appropriate use of charts for child care 182 (60.7) 118 (39.3) Improve health systems 212 (70.7) 88 (29.3) Improve family and community health adherence 204 (68.0) 96 (32.0) Improve uptake of family planning 111 (37.0) 189 (63.0) Improve child safety 167 (55.7) 133 (44.3) Figure 5 is a box plot depicting the composite scores of knowledge on IMNCI. The median composite knowledge score on the IMNCI components was 3 (IQR: 2 – 4). About a third of the respondents (35.3%) had scores less than or equal to the median score of 3. Respondents Figure 4: Box plot showing composite scores for knowledge on IMNCI components 42 Composite scores for knowledge on IMNCI components 0 2 4 6 University of Ghana http://ugspace.ug.edu.gh 4.3.1 Knowledge on child or neonate assessment Table 5 provides a summary of respondents’ knowledge on child or neonate assessment. Of all respondents, 41.3% did not rightly identify vomiting as a sign of serious illness in children requiring a referral, whereas 39% and 46.3%, respectively, wrongly identified diarrhoea and irritability, as signs of serious illness requiring a referral. Table 5: Knowledge of child assessment Knowledge of child assessment Number Percent Vomiting is a sign of serious illness requiring a referral (n=300) Yes 176 58.7 No 124 41.3 Convulsion is a sign of serious illness requiring a referral (n=300) Yes 261 87 No 39 13 Lethargy is a sign of serious illness requiring referral (n=300) Yes 245 81.7 No 55 18.3 Diarrhoea is a sign of serious illness requiring referral (n=300) Yes 117 39 No 183 61 Jaundice is a sign of serious illness requiring referral (n=300) Yes 178 59.3 No 122 40.7 Child not feeding well is a sign of serious illness requiring referral (n=300) Yes 207 69 No 93 31 Irritability is a sign of serious illness requiring referral (n=300) Yes 139 46.3 No 161 53.7 Figure 6 shows a summary of the composite scores for knowledge on assessment of neonatal and childhood illnesses. The median composite score for knowledge on assessment according to the IMNCI protocol was 6 (IQR: 5 – 7). The total composite score if all items were answered as 43 University of Ghana http://ugspace.ug.edu.gh recommended by the IMNCI protocol was 10. The proportion of respondents who had a score equal to or lower than the median score was 63.2%. Respondents Figure 5: Box plot showing the composite score for knowledge on child assessment 4.3.2 Knowledge on classification and treatment of neonatal and childhood illnesses Table 6 indicates the knowledge of respondents on classification and treatment of neonatal and childhood illnesses. About half of the respondents (49.3%) wrongly classified persistent diarrhoea as either a child frequently having diarrhoea over a period of 1 month or a child having several episodes of diarrhoea a day. Of the respondents, only 61.3% identified keeping an infant warm through skin-to-skin contact care as important care for a young infant, as defined by the IMNCI protocol. On feeding, only 66.3% knew that exclusive, on-demand breastfeeding for at least 6 months from birth is recommended 44 Composite scores for knowledge on child/infant assessment 10 2 4 6 8 University of Ghana http://ugspace.ug.edu.gh for sick young infants. Sixty-nine out of 300 respondents (23%) did not appropriately identify weight-for-age as an important measurement of wasting. Table 6: Knowledge on classification and treatment Knowledge on classification and treatment No. % Why is it important to correctly identify and manage pneumonia? (n=298) Accurate response 266 89.3 Inaccurate response 32 10.7 What are the critical treatments for children with diarrhea and dehydration? (n=300) Accurate response 275 91.7 Inaccurate response 25 8.3 What is persistent diarrhoea? (n=300) Accurate response 152 50.9 Inaccurate response 148 49.3 What would you give to children with high fever? (n=300) Accurate response 251 83.7 Inaccurate response 49 16.3 Which of the following is an important measurement of wasting? (n=300) Accurate response 231 77.0 Inaccurate response 69 23.0 Why do young infants require different care than sick children? (n=300) Accurate response 236 78.7 Inaccurate response 64 21.3 Which of the following is important care for a young infant? (n=297) Accurate response 182 61.3 Inaccurate response 115 38.7 What are the feeding recommendations for sick young infants? (n=300) Accurate response 199 66.3 Inaccurate response 101 33.7 * Denominator (n) varies in each case based on the total number of respondents who gave responses to that particular question 45 University of Ghana http://ugspace.ug.edu.gh The median composite score for knowledge on the classification and treatment of neonatal and childhood illnesses is shown in Figure 7. A little over half of the respondents (52.5%) had composite scores lower than or equal to the median score. Respondents Figure 6: Box plot showing the composite score for knowledge on classification and treatment 4.3.3 Overall knowledge on IMNCI Figure 8 shows the distribution of the composite scores for overall knowledge on IMNCI. The composite scores for knowledge on IMNCI components - assessment, and classification and treatment - were summed to produce the overall composite score. The 46 Composite score for knowledge on classification & treatment 10 0 2 4 6 8 University of Ghana http://ugspace.ug.edu.gh median score was 16 (IQR: 13 – 19). The modal score was 23 and the least frequent score was 24. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Composite scores for overall knowledge on IMNCI Figure 7: Composite scores on overall knowledge on IMNCI 47 Percent of respondents 10 15 0 5 University of Ghana http://ugspace.ug.edu.gh 43.3% 56.7% High knowledge Low knowledge Figure 8: Respondents’ Overall level of knowledge on IMNCI Table 7 further summarises the association between different characteristics of respondents and level of knowledge. Age (p=0.001), religion (p=0.01), health facility (p <0.001), working experience at the current facility (p=0.017) and IMNCI training (p<0.001) were significantly associated with the level of knowledge in bivariate analysis. Sex (p=0.422), marital status (p=0.809) and professional category (p=0.23) were not significantly associated with the level of knowledge on IMNCI. 48 University of Ghana http://ugspace.ug.edu.gh Table 7: Socio-demographic characteristics associated with the level of knowledge on IMNCI (Bivariate analysis) Characteristic Level of knowledge P-value Low High Age (n=291) 0.001** 20 - 29 years 83 (69.2) 37 (30.8) 30 - 39 years 74 (48.3) 79 (51.7) ≥ 40 years 8 (44.4) 10 (56.6) Sex (n=291) 0.422 Female 142 (55.7) 113 (44.3) Male 22 (62.9) 13 (37.1) Marital Status (n=291) 0.809 Single 95 (57.6) 70 (43.4) Married 66 (54.5) 55 (46.5) Divorced 3 (75.0) 1 (25.0) Cohabiting 1 (100.0) 0 (0.0) Religion (n=291) 0.01* Christianity 152 (55.3) 123 (44.7) Islam 13 (86.7) 2 (13.3) Traditional African religion 0 (0.0) 1 (100.0) Professional category (n=291) 0.23 Community Health Nurse 38 (55.9) 30 (44.1) Midwife 35 (66.0) 18 (34.0) Registered General Nurse Diploma 55 (50.5) 54 (49.5) Degree Nurse 20 (71.4) 8 (28.6) Medical Doctor 15 (53.6) 13 (46.4) < 0.001*** Health Facility (n=291) Princess Marie Louis Hospital 32 (34.8) 60 (65.2) Ussher Polyclinic 29 (63.0) 17 (37.0) 49 University of Ghana http://ugspace.ug.edu.gh Mamprobi Polyclinic 81 (69.2) 36 (30.8) Dansoman Polyclinic 23 (63.9) 13 (36.1) Working duration at the facility (n=291) 0.017* Less than 1 year 37 (63.8) 21 (36.2) 1 - 3 years 73 (62.9) 43(31.1) 4 - 5 years 34 (42.0) 47 (58.0) More than 5 years 21 (58.3) 15 (41.7) Had IMNCI Training (n=283) <0.001*** Yes 75 (46.7) 89 (54.3) No 86 (72.3) 33 (27.7) p<0.05* p<0.01** p<0.001*** Tables 8a and 8b further show the results of multivariable logistic analyses that were performed on variables that showed statistical significance in the bivariate analysis in Table 7. After adjusting for religion, health facility, and working duration at health facility, the odds of having high knowledge was 1.9 times greater among respondents aged 30 to 39 years compared to those aged between 20 and 29 years (AOR= 1.93; 95% CI: 1.06 – 3.49) (see table 8b). There is a 77% reduced odds for a respondent who works at Mamprobi polyclinic to have high knowledge on IMNCI compared to those who work at the Princess Marie Louis children hospital, after adjusting for age, religion, working duration at health facility and IMNCI training (AOR= 0.26; 95% CI: 0.14 – 0.48). Being 40 years or older (AOR= 2.25; 95% CI: 0.69 – 7.30, p=0.417), working at Ussher polyclinic (AOR= 0.50; 95% CI: 0.21, 1.19, p= 0.117), Dansoman polyclinic (AOR= 0.45; 95% CI: 0.18, 1.11, p= 0.083) and having worked at a health facility for 4 to 5 years (AOR= 1.28; 95% CI: 0.55, 2.99, p= 0.566) were independently associated with level of 50 University of Ghana http://ugspace.ug.edu.gh knowledge but were not significant after adjusting for significant variables. Having been trained on IMNCI was associated with 3 times higher odds of having a high level of knowledge compared to having never been trained (AOR= 2.99; 95% CI: 1.62, 5.53). Table 8a: Factors associated with level of knowledge on IMNCI (Logistic regression analysis) Variables Level of knowledge Unadjusted OR (CI) p-value Low (%) High (%) Age (Ref: 18 - 29 years) 30 - 39 years 83 (28.5) 37 (12.7) 2.39 (1.45, 3.95)* 0.001** ≥ 40 years 74 (25.4) 79 (27.1) 2.8 (1.02, 7.68)* 0.045* Religion (Ref: Christianity) 152 (52.2) 123(42.3) Islam 13 (4.5) 2 (0.7) 0.19 (0.04, 0.86)* 0.031* Health Facilities (Ref: Princess 32 (11.0) 60 (20.6) Marie Louis Hospital) Ussher polyclinic 29 (10.0) 17 (5.8) 0.31 (0.15, 0.65)* 0.002** Mamprobi polyclinic 81 (27.8) 36 (12.0) 0.24 (0.13, 0.42)* <0.001*** Dansoman Polyclinic 23 (7.9) 13 (4.5) 0.30 (0.13, 0.67)* 0.003** Working duration at Facility 37 (12.7) 21 (7.2) (Ref: Less than 1 year) 1 - 3 years 73 (25.1) 43 (14.8) 1.04 (0.54, 2.00) 0.911 4 - 5 years 34 (11.7) 47 (16.2) 2.44 (1.22, 4.87)* 0.012* More than 5 years 21 (7.2) 15 (5.2) 1.26 (0.54, 2.95) 0.597 Had IMNCI training (Ref: No) 75 (26.5) 89 (31.4) Yes 86 (30.4) 33 (11.7) 3.09 (1.87, 5.13)* <0.001*** *p-value<0.05; OR=odds ratio; CI= confidence interval; ref= reference group of the categories. * Denominator (n) varies in each case based on the total number of respondents who gave responses to that particular question 51 University of Ghana http://ugspace.ug.edu.gh Table 8b: Factors associated with level of knowledge on IMNCI (Logistic regression analysis) Variables Level of knowledge Adjusted OR (CI) p-value Low (%) High (%) Age (Ref: 18 - 29 years) 30 - 39 years 83 (28.5) 37 (12.7) 1.93 (1.06, 3.49)* 0.031* ≥ 40 years 74 (25.4) 79 (27.1) 1.65 (0.49, 5.51) 0.417 Religion (Ref: Christianity) 152 (52.2) 123(42.3) Islam 13 (4.5) 2 (0.7) 0.28 (0.05, 1.48) 0.135 Health Facilities (Ref: Princess 32 (11.0) 60 (20.6) Marie Louis Hospital) Ussher polyclinic 29 (10.0) 17 (5.8) 0.50 (0.21, 1.19) 0.117 Mamprobi polyclinic 81 (27.8) 36 (12.0) 0.23 (0.12, 0.44)* <0.001*** Dansoman Polyclinic 23 (7.9) 13 (4.5) 0.45 (0.18, 1.11) 0.083 Working duration at Facility 37 (12.7) 21 (7.2) (Ref: Less than 1 year) 1 - 3 years 73 (25.1) 43 (14.8) 0.66 (0.30, 1.48) 0.316 4 - 5 years 34 (11.7) 47 (16.2) 1.28 (0.55, 2.99) 0.566 More than 5 years 21 (7.2) 15 (5.2) 0.71 (0.26, 1.95) 0.504 IMNCI training (Ref: No) 75 (26.5) 89 (31.4) Yes 86 (30.4) 33 (11.7) 2.99 (1.62, 5.53)* <0.001*** *p-value<0.05; OR=odds ratio; CI= confidence interval; ref= reference group of the categories. 4.4 Adherence to use of IMNCI among respondents Table 9 summarises respondents’ adherence to the use of the IMNCI protocol in caring for sick children. Regarding the use of the IMNCI protocol at the health facility for managing sick children, 15% of respondents reported that the facilities where they work 52 University of Ghana http://ugspace.ug.edu.gh do not use it; 37.8% of this proportion were workers at the Ussher polyclinic and 28.9% were workers at the Dansoman polyclinic. Those who confirmed not using the IMNCI protocol in their practice formed 17.7% of respondents; approximately two-thirds of this proportion was either community health nurses or midwives while 28.3% were registered general nurses (diploma). Counselling on the administration of oral medication (98%), feeding and breastfeeding (98.3%) were almost universally done according to the recommendations of the IMNCI protocol. Table 9: Reported Adherence to IMNCI protocol Questions to assess adherence to IMNCI protocol Number Percent Facility uses the IMNCI protocol in managing sick children (n=299) Yes 254 85 No 45 15 Personal use of the IMNCI protocol in practice (n=300) Yes 247 82.3 No 53 17.7 Usually checks and records the child’s weight (n=300) Yes 288 96 No 12 4 Usually asks for the vaccination card of the child (n=298) Yes 290 97.3 No 8 2.7 Usually gives one or more classifications to the child (n=298) Yes 277 93 No 21 7 Usually explains to the caregiver how to administer oral medication (n=298) Yes 292 98 No 6 2 Usually explains the need to give more liquid and breast milk at home (n=299) Yes 294 98.3 No 5 1.7 Usually explains the need to continue feeding and breastfeeding at home? (n=297) Yes 292 98.3 No 5 1.7 Table 10 is a continuation of the summary of adherence to IMNCI protocol. Respondents who do not routinely ask if the child is able to drink or breastfeed formed 16.3% of the respondents. 53 University of Ghana http://ugspace.ug.edu.gh Twenty-two percent (22%) of respondents confirmed that they do not routinely ask if the child has a cough or difficulty breathing, and 18% do not routinely ask if the child has diarrhoea. While 14.3% do not look for visible severe wasting, 31% do not look for the child visibly being awake. Table 10: Adherence to IMNCI protocol Questions to assess adherence to IMNCI protocol Yes n (%) No n (%) Questions ask before starting treatment of a sick child (n=300) Is the child able to drink or breastfeed? 251 (83.7) 49 (16.3) Does the child vomit everything? 270 (90.0) 30 (10.0) Does the child have convulsions? 255 (85.0) 45 (15.0) Does the child have diarrhoea? 246 (82.0) 54 (18.0) Does the child have a cough or has difficulty breathing? 234 (78.0) 66 (22.0) Signs/symptoms looked out for (n=300) Whether the child is visibly awake 207 (69.0) 93 (31.0) Visible severe wasting 257 (85.7) 43 (14.3) Palmar pallor 247 (82.3) 53 (17.7) Oedema of both feet 236 (78.7) 64 (21.3) Figure 10 shows a box plot of the composite scores for adherence to IMNCI protocol. The median score was 19 (IQR: 17 – 20). The scores ranged from 7 to 21. The proportion of respondents who had low adherence was 58.7%. 54 University of Ghana http://ugspace.ug.edu.gh Respondents Figure 9: Box plot of composite scores for adherence to IMNCI protocol 4.5 Factors associated with adherence to IMNCI protocol Table 11 shows bivariate analysis of factors associated with reported adherence to use of the IMNCI protocol in caring for sick children. Age (p<0.001), health facility (p<0.001), working duration (p<0.001) and level of overall knowledge on IMNCI (p<0.001) were significantly associated with IMNCI adherence. 55 Composite scores for IMNCI Practices 10 15 20 5 University of Ghana http://ugspace.ug.edu.gh Table 11: Bivariate analysis of factors associated with adherence of IMNCI protocol Variables Adherence P-value Low High Age (n=293) <0.001*** 18 - 29 years 80 (27.3) 40 (13.7) 30 - 39 years 89 (30.4) 66 (22.5) ≥ 40 years 3 (1.0) 15 (5.1) Sex (n=292) 0.413 Female 151 (51.7) 109 (37.3) Male 21 (7.2) 11 (3.8) Marital Status (n=293) 0.077 Single 102 (34.8) 63 (21.5) Married 64 (21.8) 57 (19.5) Divorced 5 (1.7) 0 (0.0) Cohabiting 1 (0.3) 1 (0.3) Religion (293) 0.136 Christianity 159 (54.3) 118 (40.3) Islam 12 (4.1) 3 (1.0) Traditional African religion 1 (0.3) 0 (0.0) Professional category (n=293) 0.307 Community Health Nurse 45 (15.4) 25 (8.5) Midwife 32 (10.9) 21 (7.2) Registered General Nurse Diploma 58 (19.8) 52 (17.7) Degree Nurse 20 (6.8) 8 (2.7) Physician Assistant 2 (0.7) 4 (1.4) Medical Doctor 15 (5.1) 11 (3.8) Health Facilities (n=293) <0.001*** Princess Marie Louis Hospital 29 (9.9) 63 (21.5) Ussher Polyclinic 38 (13.0) 7 (2.4) Mamprobi Polyclinic 81 (27.6) 39 (13.3) Dansoman Polyclinic 24 (8.2) 12 (4.1) Working duration at Facility (n=293) <0.001*** Less than 1 year 46 (15.7) 13 (4.4) 1 - 3 years 69 (23.5) 47 (16.0) 4 - 5 years 35 (11.9) 49 (16.7) More than 5 years 22 (7.5) 12 (4.1) Supervision (n=291) 0.747 Yes 33 (11.3) 25 (8.6) No 138 (47.4) 95 (32.6) Levels of Knowledge (n=285) <0.001*** Low 115 (40.4) 46 (16.1) High 51 (17.9) 73 (25.6) p<0.05* p<0.01** p<0.001*** 56 University of Ghana http://ugspace.ug.edu.gh Tables 12a and 12b further provide information on multivariable logistic regression analyses that were performed on variables that were statistically associated with adherence in the bivariate analysis in table 11. The odds of adhering to the IMNCI protocol in caring for sick children is 93% less among respondents aged between 18 and 29 years (AOR=0.07; 95% CI: 0.01 – 0.32) and 95% less among those aged between 30 and 39 (AOR=0.05; 95% CI: 0.01 – 0.28) compared to those aged 40 year or above, after controlling for all other factors likely to influence the relationship. Regarding the relationship between health facilities and adherence, there is a 86%, 69% and 75% reduced odds of adhering to the IMNCI protocol among care providers at the Ussher polyclinic (AOR= 0.14; 95% CI: 0.05 – 0.39), Mamprobi polyclinic (AOR= 0.31; 95% CI: 0.17 – 0.62) and Dansoman polyclinic (AOR= 0.25; 95% CI: 0.10 – 0.65) respectively, compared to those who work at the Princess Marie Louis Hospital, after adjusting for other variables of interest. Health professionals who had worked for 1 to 3 years at their current health facilities had a 2.41 times greater odds of adhering to the IMNCI than their colleagues who had been working for less than 1 year (COR=2.41; 95% CI: 1.17 – 4.94). However, this association was not significant after controlling for other characteristics. After adjusting for significantly associated factors, health professionals caring for children who had been working for 4 to 5 years at their current facilities were 3.27 times more likely to be adhering to the IMNCI protocol compared to those who had been working for less than 1 year (AOR= 3.27; 95% CI: 1.30 – 8.21; p<0.001). 57 University of Ghana http://ugspace.ug.edu.gh Table 12a: Logistic regression analysis of factors associated with IMNCI adherence p-value Variables Adherence Unadjusted OR (CI) Poor (%) Good (%) Age Ref: ≥ 40 years 3 (1.0) 15 (5.1) 18 - 29 years 80 (27.3) 40 (13.7) 0.10 (0.03, 0.37)* <0.001*** 30 - 39 years 89 (30.4) 66 (22.5) 0.15 (0.04, 0.53)* 0.003** Health Facilities Ref: Princess Marie 29 (9.9) 63 (21.5) Louis Hospital Ussher polyclinic 38 (13.0) 7 (2.4) 0.08 (0.03, 0.21)* <0.001*** Mamprobi polyclinic 81 (27.6) 39 (13.3) 0.22 (0.12, 0.40)* <0.001*** Dansoman Polyclinic 24 (8.2) 12 (4.1) 0.23 (0.10, 0.52)* <0.001*** Working duration at Facility Ref: Less than 1 year 46 (15.7) 13 (4.4) 1 - 3 years 69 (23.5) 47 (16.0) 2.41 (1.17, 4.94)* 0.016* 4 - 5 years 35 (11.9) 49 (16.7) 4.95 (2.33, 10.52)* <0.001*** More than 5 years 22 (7.5) 12 (4.1) 1.93 (0.76, 4.92) 0.168 Level of knowledge Ref: Low 115 (40.4) 46 (16.1) < 0.001*** High 51 (17.9) 73 (25.6) 3.58 (2.18, 5.87)* *p-value<0.05; OR=odds ratio; CI= confidence interval; ref= reference group of the categories. 58 University of Ghana http://ugspace.ug.edu.gh Table 12b: Logistic regression analysis of factors associated with IMNCI adherence p-value Variables Adherence Adjusted OR (CI) Poor (%) Good (%) Age Ref: ≥ 40 years 3 (1.0) 15 (5.1) 18 - 29 years 80 (27.3) 40 (13.7) 0.07 (0.01, 0.32)* 0.001** 30 - 39 years 89 (30.4) 66 (22.5) 0.05 (0.01, 0.28)* 0.001** Health Facilities Ref: Princess Marie Louis 29 (9.9) 63 (21.5) Hospital Ussher polyclinic 38 (13.0) 7 (2.4) 0.14 (0.05, 0.39)* <0.001*** Mamprobi 81 (27.6) 39 (13.3) 0.31 (0.17, 0.62)* polyclinic 0.001** Dansoman 24 (8.2) 12 (4.1) 0.25 (0.10, 0.65)* Polyclinic 0.004** Working duration at Facility Ref: Less than 1 46 (15.7) 13 (4.4) year 1 - 3 years 69 (23.5) 47 (16.0) 1.77 (0.76, 4.15) 0.187 4 - 5 years 35 (11.9) 49 (16.7) 3.27 (1.30, 8.21)* 0.012** More than 5 22 (7.5) 12 (4.1) 0.92 (0.28, 3.05) years 0.89 Level of knowledge Ref: Low 115 (40.4) 46 (16.1) 0.001** High 51 (17.9) 73 (25.6) 2.70 (1.51, 4.84)* *p-value<0.05; OR=odds ratio; CI= confidence interval; ref= reference group of the categories. 59 University of Ghana http://ugspace.ug.edu.gh 4.6 Chapter summary This chapter presented the results of the study. Findings showed that the proportion of respondents with knowledge of IMNCI as well as adherence to IMNCI protocol was low. After controlling for potential confounders, being within ages 30 to 39 years and health facility location/type, and having been trained on IMNCI, were found to be predictors of level of knowledge on IMNCI. The level of knowledge on IMNCI, age, health facility location/type and having worked at a particular health facility for 4 to 5 years, were strong predictors of adherence to the use of the IMNCI protocol in caring for children, after accounting for potential independently significant factors. 60 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Introduction This chapter discusses the results of the study. The chapter has been organised into the following sections: summary of the main findings, consistency of the major findings with existing research, explanation of the findings and its implications for policy and research, as well as the strengths and limitations of the study. 5.2 Summary of findings The study found most of the respondents were aged 30 to 39 years (52.7%). Based on sex, 88.3% were females. Regarding their professions, 88.3% were either nurses or midwives. The proportion of respondents who had low overall knowledge on the IMNCI protocol was 56.7%. Majority of respondents (63.2%) had low knowledge on assessment and a minority of them had low knowledge on the components of IMNCI (35.3%). About half of respondents (52.5%) had low knowledge on classification and treatment. The proportion of respondents who had low adherence to the use of the IMNCI protocol in caring for sick children was 58.7%; the low adherence was mainly in relation to the use of the IMNCI protocol and the assessment of children. Counseling was found to be almost universally done by respondents. Factors significantly associated with knowledge on IMNCI were, being between aged 30- 39 years (AOR= 1.93; 95% CI: 1.06 – 3.49) relative to being between aged 20-29 years; working at Mamprobi polyclinic (AOR= 0.26; 95% CI: 0.14 – 0.48) relative to working 61 University of Ghana http://ugspace.ug.edu.gh at the Princess Marie Louis Hospital, and having been trained on IMNCI (AOR= 2.99; 95% CI: 1.62, 5.53). Factors found to influence adherence to the use of the IMNCI protocol were being aged between 20 and 29 years (AOR=0.07; 95% CI: 0.01 – 0.32) or 30 and 39years (AOR=0.05; 95% CI: 0.01 – 0.28) relative to being aged 40 years or above; working at Ussher polyclinic (AOR= 0.14; 95% CI: 0.05 – 0.39), Mamprobi polyclinic (AOR= 0.31; 95% CI: 0.17 – 0.62) or Dansoman polyclinic (AOR= 0.25; 95% CI: 0.10 – 0.65) relative to working at Princess Marie Louis children hospital; having worked for 4 to 5 years at a health facility (AOR= 3.27; 95% CI: 1.30 – 8.21) relative to having worked for less than 1 year, and level of knowledge on IMNCI ( AOR= 2.70; 95% CI: 1.51, 4.84). 5.3 Consistency with previous research Some of the findings of the current study are comparable to those of a similar study conducted in India, where respondents aged 18 to 30 years were 39.2% (Radhika & Kasthuri, 2016) compared to the current study, where respondents in that age category are 40.2%. However, the working experience of respondents in this study are quite dissimilar to the Indian study. The proportion of professionals who had been working at their current facility for 1 to 3 years and 4 to 5 years in the Indian study was 1.5% and 19.6% respectively (Radhika & Kasthuri, 2016), whereas the proportions in the current study are 39.7% and 28.3% respectively. Regarding knowledge on IMNCI, knowledge on child assessment was lower than that on the IMNCI components, classification and treatment. It is worth noting, however, that the 62 University of Ghana http://ugspace.ug.edu.gh overall knowledge was quite low as was found in a similar study by Joshi & Vatsa (2014). According to their study, 51.4% of workers providing care to children under five had adequate knowledge of the IMNCI protocol. In the current study, the overall level of knowledge on IMNCI among the healthcare workers who provide care to children under five was quite low, with 56.7% having low knowledge. This is also consistent with a study by Khan (2009) in Pakistan where it was found that healthcare workers were 58% deficient in the knowledge on the clinical management of childhood illnesses. Another finding from the present study that is consistent with Khan's (2009) study in Pakistan is the fact that being trained on IMNCI was likely to increase the level of knowledge about the IMNCI protocol. According to their study, training was likely to increase knowledge 2 times, while the current study found that training increases the likelihood of having high knowledge by 3 times. On adherence, a study in India demonstrated that adherence to the IMNCI protocol was not satisfactory after implementation of IMNCI (Bhandari et al., 2012). Much like is found in the current study, child assessment adherence was not as expected in the study. The poor use of the IMNCI protocol in the current study was found mainly among workers in the nursing/midwifery cadre, specifically among the community health nurses, midwives and registered general nurses (diploma). The study by Bhandari et al. (2012) demonstrated that having high knowledge improved adherence to the use of the IMNCI protocol. This is consistent with the findings of the present study, which indicate that high level of knowledge about the IMNCI protocol was associated with 2.7 times higher odds of adhering to the IMNCI protocol. This fact is reinforced by the finding that the health care workers at the Princess Marie Louis hospital 63 University of Ghana http://ugspace.ug.edu.gh had better IMNCI adherence than those from the other hospitals since the former were more likely to have higher knowledge as well. Furthermore, Borghi and Prosper (2009) noted in their study that training of health care workers, the type of facility they work in and duration of field experience were the factors that influenced IMNCI adherence. This was consistent with this current study as healthcare workers who had been trained on IMNCI were more adherent. Health care workers in Princess Marie Louis Children’s Hospital were also found to be more adherent compared to the other polyclinics. This suggests a role played by the type of facility within which they worked. 5.4 Explanation of findings and implications According to this study, there is a generally low level of knowledge on the IMNCI among healthcare workers who provide care for children under five years in the Ashiedu-Keteke and Ablekuma sub-metropolitan areas of Accra. This could be attributed to a dearth of training both in-school and on-the-job on the IMNCI protocol and its use in caring for sick children. This is particularly more likely as healthcare workers who had practiced for less than a year exhibited low level of knowledge even though they were newly trained. This suggests that the workers bring poor skills to bear in providing care for children. Knowledge on IMNCI has been proven to lead to high IMNCI adherence (Bhandari et al., 2012), and this has been corroborated by the findings of the present study, where adherence to the IMNCI protocol was also low. Working at Princess Marie Louis (PML) hospital was predictive of higher level of knowledge on the IMNCI protocol. This could be because a higher proportion of the staff 64 University of Ghana http://ugspace.ug.edu.gh (72.5%) working there were trained as compared to those at the other facilities. Also, PML hospital being a children’s hospital may be more focused on child care and may have hospital-wide policies and strategies that enhance care for children. It is important that health facilities take responsibility for ensuring that their staff is trained on IMNCI to improve patient outcomes at their facility. In relation to the predictors of adherence to the IMNCI protocol, healthcare workers aged 40 years or above were better adhering to the IMNCI protocol than their younger colleagues. This may be because working for long years provides a unique perspective of how useful adherence to the IMNCI protocol may be to improving child health outcomes. Interestingly, this is seen somewhat in the finding that those who have had a 4 to 5-year experience at their current facility are 3 times more likely to have high adherence to IMNCI protocol. Also, a higher proportion of those aged 40 years or above were trained on IMNCI than the other categories. This may be because IMNCI training is not regularly organised in recent times, putting at a disadvantage the younger group of professionals. This re-emphasises a need for training in order to increase adherence to the IMNCI protocol. Though the health professional category was not a significant predictor of adherence, the proportion of those in the nursing category who have been trained (54.1%) was quite lower than that of doctors and physician assistants. It is not surprising, therefore, that adherence among doctors and physician assistants was higher compared to the various professionals in the nursing category. 5.5 Strengths and limitations One strength of this study is that it assessed knowledge on IMNCI in a holistic manner, as a number of studies conducted earlier were focused either on the only clinical care of 65 University of Ghana http://ugspace.ug.edu.gh children or on a specific cadre of health staff such as physicians or nurses. One limitation of this study is that response bias could have occurred owing to the use of self- administered questionnaires. Some respondents may have provided responses in line with protocol when indeed their practice may be at variance with those responses. 5.6 Chapter summary This chapter discussed the results of the study. The discussion illustrated that there was a low level of knowledge on IMNCI protocol. The level of adherence to IMNCI protocol was similarly low. Together, the discussion brought to the fore important knowledge deficit, which may have impacted on adherence to the use of IMNCI protocol. The next chapter presents specific recommendations in this regard. 66 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion The study sought to assess adherence to the use of the IMNCI protocol among health workers caring for children under five years in Ashiedu-Keteke and Ablekuma Sub metropolis in the Greater Accra Region. A cross-sectional study was designed and implemented to achieve this objective. Findings suggest that the overall level of knowledge on IMNCI of healthcare workers caring for children under five was low, particularly, knowledge on the child assessment, classification, and treatment. Adherence to the IMNCI protocol by the health workers was also low, although almost all respondents provided counselling on the administration of oral medication, feeding, and breastfeeding. The factors that influence the level of knowledge on IMNCI were age (being 30 to 39 years), health facility (being a worker at Princess Marie Louis Hospital) and IMNCI training. The factors that influence adherence of IMNCI protocol were age, health facility, years of experience at the health facility and the level of knowledge of the health workers. Taken together, the results of this study suggest that if quality healthcare delivery to children under five years in the health facilities studied is to be ensured, it would be important for healthcare providers not only to become aware and knowledgeable about the IMNCI protocol but also to adhere to the protocol in the delivery of health care to children. 67 University of Ghana http://ugspace.ug.edu.gh 6.2 Recommendation Based on the findings presented in this study, the following recommendations are made for policy, clinical practice and further research. 6.2.1 Policy Recommendations In the national quest to reduce infant and child mortality in order to meet the Sustainable Development Goal 3 (SDG 3), the IMNCI training which has been proven to be valuable must be incorporated in the strategy. Training on IMNCI should be scaled up among health workers who provide care to children. The Mamprobi polyclinic, Ussher polyclinic, and Dansoman polyclinic should have a deliberate plan for their staff to get trained on IMNCI. The Ghana Health Service and Ministry of Health can facilitate this training by collaborating with the relevant regulatory bodies such as the Nursing and Midwifery Council and the Medical and Dental Council for continuous professional development (CPD) accreditation to serve as an incentive for staff to take up the training. With such an arrangement, those who have not had any training on IMNCI must be targeted to fill the skills gap created by the lack of training. 6.2.2 Clinical Practice Recommendations The opportunity must be provided for trained and untrained staff to interact and share experiences. Clinical meeting presentations at the facilities should include IMNCI protocol. The nursing categories of professionals should be the target of this experiential sharing and learning to increase adherence among them. Targeting the younger group of professionals with interventions will contribute to improving adherence to the IMNCI protocol. Also, all facilities should include an introduction to the IMNCI protocol as part 68 University of Ghana http://ugspace.ug.edu.gh of the orientation for new staff providing care to children under five. Additionally, copies of the IMNCI protocol should be available in all working areas involved in childcare. 6.2.3 Recommendation for further Research Further studies should also be undertaken to assess adherence to the IMNCI protocol by observing practitioners providing care rather than using self-administered questionnaires, to estimate adherence more precisely. 69 University of Ghana http://ugspace.ug.edu.gh REFERENCES AbouZahr, C., & Berer, M. (2000). When pregnancy is over: preventing postpartum deaths and morbidity. In M. Berer & T. Ravindran (Eds.), Safe motherhood initiatives: critical issues. 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WHO Informal consultation on Fever Management in peripheral health care settings: a global review of evidence and practice. Malta. Wright, S., Mathieson, K., Lara Brearley, S., Jacobs, L. H., & Ravi, W. (2014). Ending newborn deaths: Ensuring every baby survives. Save the Children. London. Zhang, Y., Dai, Y., & Zhang, S. (2007). Impact of implementation of integrated management of childhood illness on improvement of health system in China. Journal of Paediatrics and Child Health, 43(10), 681–685. https://doi.org/10.1111/j.1440-1754.2007.01187.x 75 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix I: Participant Information Sheet and Consent Form MASTER OF PUBLIC HEALTH DEPARTMENT OF POPULATIONS FAMILY AND REPRODUCTIVE HEALTH SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF GHANA, LEGON CONSENT INFORMATION PURPOSE OF RESEARCH You are invited to participate in a research study on Adherence to Integrated Management of Neonatal and Childhood Illnesses (IMNCI). This study is to find out the adherence level of the IMNCI protocol by health care workers (doctors and nurses) in Ashiedu-Keteke and Ablekuma Submetros in the Greater Accra Region. You were selected as a possible participant in this study because you meet our selection criteria and you were retained in our sampling. This study is looking for a minimum of 301participants. VOLUNTARY PARTICIPATION: Your participation in this study is entirely voluntary. Your decision not to participate will not have any negative effect on you or on your relation. In the course of the study you can redraw anytime you want to, without any consequences. DURATION OF STUDY INVOLVEMENT: This research study is expected to take approximately 2 months to interact with selected participants and to gather necessary information. Responses will be put together and analyzed in the next month. Final report should be complete by the end of July, 2017. 76 University of Ghana http://ugspace.ug.edu.gh PROCEDURES: Participation in this research gives you the opportunity to ask all questions you may have and further explanations will be given. SIGNING OF QUESTIONNAIRE: If you agree to participate, you will be requested to sign a consent form. This will be done after understanding the purpose of study and agreeing to be part of study. ADMINISTRATION OF QUESTIONNAIRE: A set of questions will be asked in the questionnaire for which you will be requested to provide genuine answers as much as possible. You can however decide not to answer questions you feel uncomfortable with. Each questionnaire will take less than 30 minutes to complete. RISKS: There are no risks attached to responding to the questionnaires. Your identity will not be disclosed whatsoever in this study; however for purposes of data analysis each form will be coded. PARTICIPANT RESPONSIBILITIES: As a participant, your responsibilities include: Follow the instructions and complete your questionnaires as instructed; Ask questions as you think of them; Inform the research assistant if you change your mind about staying in the study WITHDRAWAL FROM STUDY: If you first agree to participate and later change your mind, you are free to withdraw your consent and discontinue your participation in the study. Your decision will not affect you in any way. 77 University of Ghana http://ugspace.ug.edu.gh POSSIBLE RISKS, DISCOMFORTS, AND INCONVENIENCES You should talk with the research assistant if you have any such discomforts and ask questions whenever you want for clarification. POTENTIAL BENEFITS: We cannot and do not guarantee or promise that you will receive any benefits from this study. We however hope that the outcome of this study would be used to advice on policies that bother on child health especially adhering to the IMNCI protocol in the management of childhood illnesses. PARTICIPANT’S RIGHTS: You should not feel obligated to agree to participate. Your questions should be answered clearly to your satisfaction. If you decide not to participate, tell the research officer. CONFIDENTIALITY: The results of this study may be presented at scientific or public health meetings or published in scientific or public health journals. Your identity and/or your personal information or that of your relation will not be disclosed except as authorized by you or as required by law. No response given will be disclosed to any unauthorized persons. Neither your name nor any identity traceable to you or your relation will be indicated on the survey forms. CONTACT INFORMATION: Questions, Concerns, or Complaints: If you have any questions, concerns or complaints about this research study, its procedures or risks and benefits, you should ask the research assistant. Independent Contact: If you are not satisfied with how this study is being conducted, or your questions/ concerns etc. are not satisfactorily answered by the research assistant or if you have further concerns, complaints, or general questions about the research or your rights as a participant, please contact: 78 University of Ghana http://ugspace.ug.edu.gh Dr. John Kuumouri Ganle (Supervisor); School of Public Health; University of Ghana, Legon Tel: 002449957505; E-mail: zabzugu.gan@gmail.com Or Charlotte Eleanor Odeibea Okae; School of Public Health; University of Ghana, Legon Tel: 0544749099; Email: afuaokae@gmail.com STATEMENT OF CONSENT I have read this consent form. I have had the opportunity to discuss this research study with ………………………………………………………. and or his/her study staff. I have had my questions answered. The risks and benefits have been explained to me. I believe that I have not been unduly influenced by any study team member to participate in the research study by any statement or implied statements. I understand that my participation in this study is voluntary and that I may choose to withdraw at any time. I freely agree to participate in this research study. I understand that information regarding my personal identity/ that of my relation will be kept confidential. By signing this consent form, I have not waived any of the legal rights that I have as a participant in a research study. Participant signature_________________________ Date ___________________ (Day / month / year) 79 University of Ghana http://ugspace.ug.edu.gh Appendix II: Study Questionnaire No Question Response SECTION A 1. Name of Health facility ……………………………………………….. 2. How long have you been working in this Health A. Less than 1 year facility? B. 1 – 3 years C. 4 – 5 years D. More than 5 years 3. Professional Qualification Community Health Nurse Midwife Registered General Nurse Diploma Degree Nurse Physician Assistant Medical Doctor 4. Religion Christianity Islam African Traditional Religion Others (specify)………………………. 5. Age (Exact age) ……………. 6. Sex Female Male 7. Marital Status Single Married Divorced Widowed Cohabitating SECTION B: KNOWLEDGE ON IMNCI 8. Have you heard of about IMNCI? Yes No 80 University of Ghana http://ugspace.ug.edu.gh 9. If Yes, what is IMNCI? 10. Have you received any training on IMNCI? Yes If No skip to No 11. If yes, how many times? ……………………….. 12. Have you had any refresher training in the last Yes year? No 13. What are the functions of IMNCI? 14. What are the various components involved in 1. Improve health workers’ skills IMNCI? 2. Improve appropriate use of charts for child care 3. Improve health systems (Please tick all that apply) 4. Improve family and community health practices 5. Improve uptake of family planning 6. Improve child safety 15. If a child arrives at your clinic with a sign of 1. Vomiting serious illness, they should be immediately 2. Convulsion referred. What are these signs? 3. Lethargy 4. Diarrhea (Please tick all that apply) 5. Jaundice 6. Child not breastfeeding well 7. Irritability 16. When is a child considered as lethargic? A. When the child will not wake, even after shaking (Please circle most appropriate response) B. When the child is sleeping more often than usual, but will wake up if you set them down to walk C. When the child is drowsy and will not follow movement or noise in the room 17. What clinical signs can help you identify if A. Wet cough a child has pneumonia? B. Fast breathing (Please circle most appropriate response) C. Chest in drawing 18. Why is it important to correctly identify and A. Pneumonia is very common, but it is not so serious for manage pneumonia? children (Please circle most appropriate response) B. Pneumonia is a major killer of children under 5 around the world, and it requires early management C. Children with pneumonia need to be isolated from all other family members 19. What are critical treatments for children A. Oral antibiotics with diarrhea and dehydration? B. Oral rehydration therapy and zinc (Please circle most appropriate response) C. Paracetamol for discomfort 20. What is persistent diarrhea? A. When a child frequently has diarrhea over a period (Please circle most appropriate response) of 1 month, and is ill as a result B. When a child has several episodes of diarrhea a day 81 University of Ghana http://ugspace.ug.edu.gh C. When a child has an episode of diarrhea lasting 14 days or more, which is particularly dangerous for dehydration and malnutrition 21. What would you give to children with high A. Paracetamol fever? B. Amoxicillin or another antibiotic (Please circle most appropriate response) C. Fluid 22. Traci has a fever, generalized rash, runny A. She shows signs local infections of the skin nose, and mouth ulcers. How would you B. She shows clinical signs of AIDS classify? C. Measles with mouth complications (Please circle most appropriate response) 23. Which of the following is an important A. Weight-for-age measurement of wasting? B. Percentage weight gain since last visit (Please circle most appropriate response) C. Weight-for-height (or length) 24. Why do young infants require different care A. Young infants are much quicker to recover from than sick children? illness because they are (Please circle most appropriate response) young. B. Young infants show signs of illness differently. They can also become ill and die from an infection very quickly. C. Young infants very rarely get sick. 25. Which of the following is important care A. Keeping the infant loosely bundled so he can begin for a young infant? to move his arms and legs (Please circle most appropriate response) B. Keeping the umbilical cord moist so that it falls off quickly C. Keeping the infant warm through skin-to-skin care 26. What are the feeding recommendations for A. Exclusive, on-demand breastfeeding for at least 6 sick young infants? months (Please circle most appropriate response) B. Breastfeeding and additional sources of fluid, like water, to hydrate C. Soft complementary foods as soon as the child is ready 27. What are signs that a young infant is A. Breathing more than 60 breaths per minute seriously ill and needs urgent referral and B. Skin pustules care? C. Some jaundice, where the eyes are yellow but not (Please circle most appropriate response) the palms or soles SECTION C: IMNCI ADHERENCE 28. Does your facility use the IMNCI Protocol in Yes managing sick children? No 29. Do you use the IMNCI protocol in your Yes practice? No 82 University of Ghana http://ugspace.ug.edu.gh 30. Do you check and record the child’s weight? Yes No 31. Do you check and record the child’s Yes temperature? No 32. Which of the following questions do you A. Is the child able to drink or breastfeed? ask? B. Does the child vomit everything? (Please tick all that apply) C. Does the child have convulsions? D. Does the child have diarrhoea? E. Does the child have cough or has difficulty breathing? 33. Which of the following do you look for? A. Whether the child is visibly awake B. Visible severe wasting (Please tick all that apply) C. Palmar pallor D. Oedema of both feet 34. Do you ask for the vaccination card of the Yes child? No 35. If No, do you probe to ascertain if child Yes may have been vaccinated? No 36. Do you give one or more classifications to Yes the child? No 37 In your experience, which of the following A. An injection do you usually administer or prescribe? B. ORS (Please tick all that apply) C. Other oral medication 38. Do you explain to the caregiver how to Yes administer oral medication? No 39. Do you explain the need to give more liquid Yes and breastmilk at home? No 40. Do you explain the need to continue Yes feeding and breastfeeding at home? No 83 University of Ghana http://ugspace.ug.edu.gh SECTION D: FACILITY-RELATED FACTORS AFFECTING IMNCI PRACTICE 1. Has there been any form of supervision on Yes IMNCI at this facility within the last three No months? 2. If yes, how many? …………………… 3. Does this facility have a designated corner or Yes room for IMNCI? No 4. Does the facility have the following? 1. A spacious IMNCI corner that ensures privacy 2. IMNCI protocol such as Booklets, charts, Please tick all that may apply posters 3. Weighing scale 4. Veronica bucket/tap with running water 5. Drinking water 6. Clean cup with lid 7. Thermometer 8. Food samples for demonstration 9. Needles and syringes for vaccination 10. Functional sterillizer, cooker or stove 11. Functional refridgerator 12. Accessible transportation for referral 5. Does the facility have the following oral 1.Amoxicillin medication available today? 2.Amoxicillin/clavulanic acid 3.ORS Please tick all that may apply 4.Zinc Tablet 5.Cotrimoxazole 6.Artesunate/Amodiaquine 7.Artemether/Lumefantrine 84 University of Ghana http://ugspace.ug.edu.gh 8.Cefuroxime 9. Metronidazole 10.Vitamin A 11.Iron 12.Paracetamol/Aspirin 13.Mebendazole 14. Tetracycline Eye ointment 15. Gentian violet 85 University of Ghana http://ugspace.ug.edu.gh Appendix III: Letter of Ethical Clearance 86 University of Ghana http://ugspace.ug.edu.gh 87 University of Ghana http://ugspace.ug.edu.gh 88 University of Ghana http://ugspace.ug.edu.gh 89