Assessment of knowledge levels of Integrated Management of Neonatal and Childhood illness among health care providers working in round the clock PHCs
The National Rural Health Mission (NRHM) programme emphasizes institutional deliveries for all pregnant women as a means to bring down maternal and neonatal deaths. In order to provide quality health care to women who deliver at the PHCs, training the health care providers in safe delivery and newborn care is crucial. In order to address reduction in neonatal mortality and incorporate inexpensive and effective interventions within the existing child survival programmes, India's Integrated Management of Childhood Illnesses IMCI Adaptation Committee developed the Integrated Management of Neonatal, Childhood Illnesses (IMNCI) Strategy. In the recent times, the IMNCI strategy has emerged as a promising approach to deal with Infant Mortality Rate (IMR) reduction. Three periods (gestation, delivery, and the neonatal period) have been identified as essential entry points for intervention in order to reduce Neonatal Mortality Rate (NMR).Â The neonatal period was chosen as the focus for IMNCI intervention as gestation and delivery were already covered under the Reproductive and Child Health (RCH) programme and the Integrated Child Development Scheme (ICDS). UNICEF introduced IMNCI as a pilot project in Medak district, Andhra Pradesh in 2007 with an objective to expand to other parts of the state in a phased manner. The infant mortality rate (IMR) of Medak district was 65 per 1000 live births in the year 2007 (Baseline survey on RCH II, Andhra Pradesh, 2007), way below the target 30 per 1000 live births by 2010 (Millennium Development Goal, 2000). In order to enhance the knowledge and skills of health care providers regarding essential newborn care to bring about an overall reduction in IMR, IMNCI training was conducted for health care providers in Medak district.
The objective of our study was to assess the impact of the IMNCI training on the knowledge levels among Health Care Providers in Medak district.
Review of Literature: A number of studies have appeared in the literature regarding the community or village health workers making a positive impact on maternal and neonatal health in rural communities of India (Abhay Bang, 2000, Abiram et al, 2005). The provision of home-based neonatal care by community health workers effectively reduced neonatal mortality in rural Maharastra where the baseline (1993-95) neonatal mortality rate were 62 and 58 per 1000 live births in the intervention and the control areas respectively (Abhay Bang, 2000). The village health workers in the intervention areas were trained in neonatal care. The intervention was associated with a reduction in neonatal deaths that occurred due to birth asphyxia, premature birth, low birth weight, hypothermia, breastfeeding problems and neonatal sepsis. Among the study population, the intervention reduced neonatal and infant mortality substantially.
A case study conducted by Abiram et al (2005) on short term effects of IMNCI in Orissa revealed that there was an improvement in case management skills among health care providers and had resulted in reduced prevalence of major neonatal illnesses. Gupta and Aggarwal (2007) found that there were 82.2% mothers who practiced breast feeding effectively after training as compared to less than 50% mothers' breast feeding prior to IMNCI training. This study compared pre and post training effects on breast feeding practices among mothers in rural area. Interestingly, earlier studies have examined the impact of IMNCI on outcomes. However, they have not evaluated knowledge of the health care workers. â¬ËPrevious studies have not looked at increase in the knowledge of health care providers themselves and only examined the impact of training programme. We tried to address this gap in the literature.'
Simple Random Sampling(SRS) technique was used to sample one third of the 36 round the clock PHCs. Health care providers at the 12 selected round the clock PHCs were requested to participate in the cross-sectional survey. The participation rate was 100%. The main care givers Auxiliary Nurse Midwives (ANMs) and Staff Nurses (SN) providing delivery and newborn care services were interviewed. A total of 85 Health Care Providers participated in the knowledge survey that was conducted from 1st March 2010 to 30th May 2010. The study included assessment of knowledge component only and no skill component as it would have been difficult to differentiate between skill sets of ANMs and SNs in a setting where deliveries occur less frequently and at odd hours. Â
Participants who received IMNCI training were compared with those who did not in terms of the distribution of socio demographic characteristics. The tool (semi structured questionnaire) for measuring basic knowledge on essential newborn care was adapted from Department of Pediatrics, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences (AIMS), New Delhi. The tool was pilot tested among health care providers of Regode PHC in Medak district and modified accordingly to suit the local language (See Appendix) and was administered by a face to face interview. The questionnaire was answered independently by HCP's at each of their PHC. It consisted of 12 questions covering basic aspects of neonatal care. Â The emphasis was on six components of neonatal care as covered under the IMNCI training: clean chain, cord care, breast feeding, warm chain, immunization and identification of at risk neonate from normal neonate. It did not include antenatal, intranatal and post natal aspects of IMNCI. The selection of questions under each topic was based on their relevance for neonatal survival in the study area. The questionnaire was a mix of multiple-choice questions, semi open ended question & chart display questions to assess the knowledge of neonatal care. The maximum possible points an individual could score on this was 67 points. To compare the knowledge level between the trained and untrained participants on each component of the questionnaire, we estimated the difference in mean scores on each component and its 95% confidence interval.Â Comparisons were carried out separately for ANMs and staff nurses (Tables 1 & 2).
The study was carried out in Medak district where a total of 36 round-the-clock PHCs were functioning with a staff of 453 Auxiliary Nurse Midwives (ANMs) and 43 staff nurses. The Participation was 100% (n=85). Among the respondents, 40% (34/85) were trained ANMs, 34.11% (29/85) untrained ANMs, 14.11% (12/85) trained staff nurses and 11.76% (10/85) untrained staff nurses. The mean age of the respondents was 37 years; 100% (85/85) were female and 54.11% were IMNCI trained and 45.87% untrained. 54.11% of the health care providers interviewed had undergone IMNCI training by 2007 on essential newborn care. As far the staff nurses category, trained nurses had 9.5 yrs of work experience compared to the untrained nurses with an average of 6.9 yrs.
All ANMs had Multi Purpose Health Worker (MPHW) training and all nurses were GNM qualified.Â The study found that the same percentage of HCP's were trained suggesting that both staff nurses and ANMs received training jointly. The average time since receiving IMNCI training among the HCPs in our study was two years. The average score among all HCPs was 37.01% points. The trained HCPs had an average score of 40.31 points and untrained HCPs had scored 33.71 points.
Difference of Mean
Neonate at Risk
Table 1: Difference of Mean scores & 95% confidence limits (C.I) among Trained Vs Un-trained ANMs.
Difference of Mean
Neonate at Risk
Table 2: Difference of Mean scores & 95% confidence limits (C.I) among Trained Vs Un-trained Staff Nurses.
The study found a significant difference in scores obtained by IMNCI untrained and trained Health Care Providers. IMNCI trained HCP's had scores significantly higher than untrained HCPs in components that play a pivotal role in neonatal survival such as identifying a neonate at risk, maintaining clean chain to prevent neonatal sepsis, maintaining warm chain to prevent hypothermia and breast feeding. The HCPs attending the deliveries at round the clock PHCs have to deal with cord care immediately after birth and hence the questionnaire included questions on cord care. Knowledge level on immunization component however, had no significant difference between the trained and untrained HCPs. This could be due to the emphasis laid on routine immunization of all children at the PHCs. However, HCPs knowledge on immunization although very important does not contribute to neonatal survival. The training of IMNCI commenced in 2007 and HCP's who were employed at that point in time had the benefit of training. The infant mortality rate (IMR) of Medak district was 65 per 1000 live births in the year 2007 (Baseline survey on RCH II, Andhra Pradesh, 2007). The neonatal mortality rate (NMR), the probability of dying in the first 28 days of life comprises about 70 percent of all infant deaths in the state of Andhra Pradesh. Thus, by focusing on neonatal care, health care providers can significantly contribute towards the MDG (30 per 1000 live births by 2010). The state government recruited ANMs under the National Rural Health Mission (NRHM) to provide basic and emergency obstetric and neonatal services in rural areas in 2008. This factor should be considered in future efforts for training or skill building programmes intended towards HCPs for improving the neonatal health situation in Medak district.Â Transforming knowledge to action is important for improving the neonatal health situation in round the clock PHCs.
Conclusion: Overall, the findings point a marginally high level of knowledge in essential newborn care among the IMNCI trained health care providers. Trained HCPs had higher scoring on all key components required for neonatal survival. Thus, we can recommend IMNCI training for all health care providers working in round the clock primary health centers providing maternal and newborn services.
1)Â Â Â Â Â IMNCI training needs to be extended to untrained health workers providing neonatal services in round the clock PHCs of Medak district. 2) To have a periodic refresher training on IMNCI. 3) To undertake further studies on skill enhancement and impact of IMNCI training in Medak district. 4) To expand IMNCI training to other parts of state and to newly recruited ANMs and SNs.