5. RESULTS
6.1. Findings of the study
Study results revealed that sector of work, gender, designation, level of qualification and other courses on child health had no interaction with knowledge score. IMNCI training during studies, graduation from Sudan and graduation year up to 1980 showed a positive association with knowledge score. In both sectors, IMNCI trained professionals and graduate from Sudan scored better on knowledge scale than untrained and graduation from other countries. Health professionals graduated up to 1980 scored higher as shown in table 7.There is mild difference of mean obtained score among health professionals having graduation between 1980 and 2010.
During the period of survey very few Saudi doctors were working in study sectors and only four from Sabya sector participated in the study. They all were not trained in case management of IMNCI with mean knowledge scores of only 4.34 out of 15. More than half of nurses working in Sabya sector were Saudi nationals compared to only one in Tathleeth sector. None of the Saudi nurses participated in the survey; their poor response might be due to poor English language proficiency or self-perceived expected low performance.
The participation of healthcare professionals in this survey is small and difficult to draw a conclusion that survey results are representative of knowledge level of other health workers working elsewhere in the KSA.
6.2 Validity and reliability of study
Convenience census survey among healthcare providers irrespective of their training status regarding IMNCI case management strategy is the strength of this study. Survey among healthcare professionals of different nationalities is also support the validity of this study. Work place (job) in the same study sector and in big city is also strength of my study because it was easy to approach the participants of countryside and main city health centers.
6.2.1. Response rate Issues
For the researchers, response or reply rate is an issue of worry in a study most of the time. Reply or return rate varies depending upon mode, theme and nature of surveys (Braithwaite et al. 2003, Pulakka 2009).The return rate is small in the study (43.28%) while in another IMNCI knowledge score study conducted in Pakistan in 2008, the response rate reached up to 75.2% (Khan 2009).
For the study, all accessible study participants were contacted personally by researchers and given the questionnaire. To enhance the return rate of questionnaires during study period, all feasible survey participants reminded twice to accomplish and return survey questionnaires.
Accessible participants of study had an appropriate time to fill in and return questionnaires.
In questionnaire studies, respond or reply rate by considered as indirect measure of non-response bias (Asch et al. 1997, Pulakka 2009,). To evaluate non-non-response bias, researchers normally correlate between major variables of respondent and non-respondents (Cummings et al.
2001, Pulakka 2009). In this survey, major return failure is hard to investigate due to unidentified nature of appraisal through questionnaire. Majority of the non-responders were Saudi nurses because of language barrier and some others refused to participate as having fear in mind of hidden aims of MOH Saudi Arabia.
Almost all probable study respondents were briefed regarding unidentified and unknown nature of questionnaire still some of the participants showed their verbal reservations by saying that the
information given by them may be used for some kind of evaluation by the Ministry of Health KSA.
6.2.2. Internal validity and bias control
A pre-used questionnaire was structured according to IMNCI guidelines of WHO for the survey to raise the internal validity. The same questionnaire was used for the evaluation of trainee doctors regarding case management in IMNCI in Pakistan during the year 2008. With few modifications, this questionnaire was used for survey by the research team in KSA to evaluate knowledge in IMNCI case management. The study questionnaire was prepared in English with the intension that all healthcare professionals would have their professional study in English, so language barrier issue was not a matter of concern in the study questionnaire. There is mild relationship between respond rate by participants and span of questionnaire as shown in some surveys (Pulakka 2009). In this study, the questionnaire was of suitable length, easy to understand and fill-in.
To enhance the respond rate in the survey, it is better to remind the study participants again and again effectively. So during the survey period two reminders were sent to the target population of this survey (Beebe et al. 2007, Pulakka 2009, Wakley 2005). Questionnaire was consisted close and open ended questions. By open ended questions, participants were given a chance to clarify and elaborate their answers. This action helped further to increase the sample size of the survey. Feasible survey participants were granted optimum time to think, fill and return survey questionnaires.
6.2.3. External validity
The study participants are doctors and nurses working in PHCCs in two sectors of KSA during the survey period. But the respondents are those who accepted and filled the questionnaire. So the eligible population for survey was only those who accepted and filled the questionnaire according to guidelines.
The main objective of this study and collection of data was to comprehend an illustrative community of healthcare workers in both sectors such as Tathleeth and Sabya. One criterion for inclusion was working in the respective sector during the survey period. Thus, the respondents stand for the target population.
The survey sectors were well represented in the survey. Out of 99 respondents, none reported any difficulties in understanding the survey questionnaire, which means that study respondents participated in the survey with kind heart and free of cost.
Response rate in the survey is 43.2% and seemed to be small. It is possible that some participants might return more than one answer sheets, in spite of purifying collected information properly before analysis. Validity of the survey is not seemed to be affected by issues such as less respond rate and proper cleansing of data information received through questionnaire.
6.3 Correlation with previous studies
Poor neonatal and child health, mainly affecting developing countries, are global concerns for decades. A great variation exists in death rates and causes of mortality in different geographical regions. To tackle this global challenge WHO and UNICEF adopted IMNCI strategy (UNICEF 2015).
Over the years, implementation of IMNCI strategy has delivered better care to sick children (Pariyo et al. 2005, Kumar et al. 2009). This study confirms better knowledge in terms of knowledge score among those who have training in IMNCI clinical case management and many earlier studies have confirmed that improved knowledge is beneficial at health centers for the treatment of ill babies. (Gouws et al. 2004, Kumar et al. 2009).
Overall, Sudanese got highest score in this survey. Indian and Pakistani doctors and nurses who were trained in IMNCI program also scored a bit higher. This may be because of adoption of IMNCI strategy in these countries. Results of this survey are relevant with a previous study done in Pakistan where trained health care staff scored higher compared to untrained (9.7 vs. 5.1).
Surprisingly, the mean knowledge score obtained by Pakistani doctors is almost the same (7.5 vs. 7.6.) as was reported in a survey conducted in 2008 (Khan 2009). An Indian study also found similar results; trained personnel got an average score 40.31 points compared to 33.71 in untrained (Armstrong et al. 2004).
Some earlier studies have related level of qualification (nursing / medicine) and job position as predictors of knowledge score. Our results did not very much different from earlier results.
(Gouws et al. 2004, Arifeen et al. 2004, Khan 2009).
Many studies were done where target population belong to only one nationality but in our study healthcare professionals from 10 different nationalities who studied in 12 different countries participated and their knowledge of clinical case management of IMNCI varied a lot.
6.4 Limitations of the present study
It was tried to minimize the limitations and assure validity in the current study but still there are some limitations about questionnaire, sample collection and recall issues.
6.4.1. Questionnaire and its limitations
The survey questionnaire was prepared in the English language. Most of the participants are foreign nationals and it was assumed that they would have completed their studies in English.
Simple words and terms were used in questionnaire, so that all participants could understand and answer the questions easily. In spite of this there was possibility of not to understand few terms and difficulty in filling the questionnaire. This factor might have effect on answering and returning the questionnaires to researchers. This issue was more with Saudi health professionals especially nurses. Saudi nurses have small participation in survey and might be due to language barrier and fear of self-perceived low performance.
Likewise under and over reporting is an issue in questionnaire survey (Sapkota et al. 2010). It is unclear that this survey caused to under or over return rate as there was no check on multiple responses by one participant in this survey.
6.4.2. Recall Issues
To evaluate the knowledge of participants, a pre-used SAQ (Self - Administered Questionnaire) was used for the survey in two sectors of KSA. Therefore by design recall bias, consultation with others sources and deliberate misreporting may not be excluded (Sapkota et al. 2010).
6.4.3. Sample collection and its limitations
Selected sectors for sample collection were chosen on easily approach basis by the researchers.
Respondents of the survey were mostly volunteers. So participants were not representative of
absolute health care professionals. That’s why the convenience or volunteer sample is lesser important than random and probability sample. On the other hand, sample size of this study is acceptable and may reduce the limitation of convenience sample. But this is yet uncertain that outcome of the survey might be concluded to all doctors and nurses working in different regions of Kingdom of Saudi Arabia
6.5 Public health implications of study
Reduction in neonatal and child health mortality and thus increased child stability are main global health threats. The survey was done to evaluate knowledge of IMNCI clinical case management among health professionals in two sectors of KSA. Indirectly, the study judged the result of training in IMNCI clinical case management on the knowledge of health professionals working in the study sectors. Improved knowledge and better implementation of clinical case management of IMNCI strategy may offer better service to children under five.
Mother and child health care facilities are adequate in KSA and indicators improved much over the years but there is always a room for improvement. This study has also offered recommendations to strengthen IMNCI strategy and train health care personnel to address child survival issue. Sound knowledge regarding IMNCI program can support in improving practices for the benefit of children.
Further discussions on IMNCI strategy should be continued. IMNCI strategy should be strengthened in KSA. From public health standpoint, rationale use of proven child health interventions like clinical case management of IMNCI may improve child survival.
6.6 Future research significance
This survey will help other researchers to do more work on child health services in future in Saudi Arabia. This study focused knowledge assessment of doctors and nurses working in two sectors of KSA. To more endorse the survey outcome, future research should be broaden to include healthcare professionals working in other sectors of KSA. It would be interesting to motivate Saudis to participate in such studies to compare them with other nationalities.
Alternately, an Arabic version of questionnaire can be used for Saudi staff to have better response rate. Future research is essential to validate the effects of IMNCI trainings on healthcare professionals and its ultimate influence on child survival.
7. CONCLUSIONS AND RECOMMENDATIONS
In summary, results of the study found a clear association between training in IMNCI case management of the participants and knowledge score obtained. Moreover, knowledge score association was also found based on nationality, country of graduation, year of graduation and duration of working experience in children ward. Results did not show any association of knowledge score with sector of work, age, gender, title of appointment, level of qualification, service duration in KSA and participation in other courses on child health. The study results seemed to support the fact that training in IMNCI case management program upgrade the knowledge of healthcare staff.
Low response rate was a weakness of the study. However, this data on knowledge of clinical case management of IMNCI from two sectors in KSA has advantage of convenience census sample. Anonymous self-administered nature of questionnaire survey did not allow investigators to look at non-responders. For better illustration of the survey experience, other sectors in KSA involving non-respondents of this study need to be investigated to better corroborate the results.
Depending on these survey results, it is recommended that clinical case management of IMNCI trainings should be implemented and strengthened in KSA. Healthcare students and working professionals should be trained for IMNCI case management which may improve the childhood survival, growth and development.
Further research should be done including PHCCs in other regions, higher level healthcare facilities and private sector healthcare facilities of KSA.
8. REFERENCES
African Medical Research Foundation (AMRF) 2007.Child Heath Course UNIT 2, Integrated Management of Childhood Illnesses.CH_Unit_2_IMCI_final.rar (Accessed on 12 April 2012) http://www.col.org/resources/crsMaterials/Pages/childHealth.aspx
Arifeen SE, Blum LS, Hoque DME, Chowdhury EK, Khan R, Black RE, Victora CG and
Bryce J. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomized study. Lancet 2004;364(9445):1595-1602.
Arifeen SE, Bryce J, Gouws E, Baqui AH, Black RE, Haque DME, Chowdhury EK, Yunus M, Begum N, Akter T, Saddique A. Quality of care for under fives in first level health facilities in one district of Bangladesh, Bulletin of World Health Organization, 2005; 83: 260-267.
Amaral J, Leite AJ, Cunha AJ, Victora CG. Impact of IMCI health worker training on routinely collected child health indicators in Northeast Brazil. Health Policy Plan. December 2005; 20 (Suppl 1): 142-148
Amin H, Yasin H, Danish, SH, Ahmad F, Rasheed S, Zehra N, Ara G. Appraisal of
knowledge, attitudes and practices of trained doctors regarding IMNCI. Pak J Med Dent 2015;
4(1):47-53.
Armstrong SJRM, Bryce J, de Savigny D, Lambrechts T, Mbuya C Mgalula L and Wilczynska K. The effect of Integrated Management of Childhood Illnesses on observed quality of care of under-five in rural Tanzania. Health Policy Plan 2004 Jan;19(1); 1-10.
Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. Journal of Clinical Epidemiology. 1997; 50:1129–1136.
Bassuni W, Abbag F, Asindi A, Al-Barki A, Al-Binali AM. Neonatal deaths in the ASIR region of Saudi Arabia: Experience in a referral neonatal intensive care unit, Annals of Saudi Medicine 1997; 17(5): 522-526
Beebe TJ, Locke GR, III, Barnes SA, Davern ME, Anderson KJ. Mixing web and mail methods in a survey of physicians. Health Services Research. 2007; 42 (3 Part 1):1219–1234.
Black R E, Morris SS, Bryce J, Where and why are 10 million children dying every year? The Lancet, 2003 Elsevier limited, volume 361, Issue 9376, 28 June 2003. Pages 2226-2234
Boynton PM, Greenhalgh T. Hands-on guide to questionnaire research: selecting, designing, and developing your questionnaire. BMJ: British Medical Journal 2004; 328(7451): 1312-1315.
Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to Conduct Surveys of Health Professionals: A Valid Alternative? Family Practice 2003; 20 (5):545–551.
Bryce J, Victora CG, Habicht JP, Vaughan JP and Black RE. The Multi-Country Evaluation of Integrated Management of Childhood Illness Strategy: Lesson for the Evaluation of Public Health Interventions, American Journal of Public Health Volume 94, No. 3; March 2004, 406-415
Bryce J, Victora CG, Habicht JP, Black RE and Scherpbier RW. Programmatic pathways to child survival: Results of multi-country evaluation of Integrated Management of Childhood Illness. Health Policy Plan. 2005 Dec;20 Suppl 1: 15-117.
Bryce J, Gouws E, Adam T, Black RE, Schellenberg JA, Manzi F, Victora CG, and HabichtJP.
Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania, Health Policy Plan. 2005a Dec;20 Suppl 1,
pg.no. i69-i76.
Chopra M, Patel S, Cloete K, Sanders D, Peterson S. Effect of an IMCI intervention on quality of care across four districts in Cape Town, South Africa,Acute pediatrics. Edition2005; Vol.
90, Pg397-401.
Cran.r-project.org. The R Project for Statistical Computing. R-2.8.1for Windows. Last changed: 22.12.2008. (Assessed on 03.10.2015). Available from:
https://cran.r-project.org/bin/windows/base/old/2.8.1/
Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Service Research. 2001; 35(6):1347–1355.
de Onis M, Blossner M, Borghi E, Morris R and Frongilla EA. Methodology for estimating regional and global trends of child malnutrition, International Journal of Epidemiology 2004;
33: 1260—12270.
Edwards P. Roberts I. Clarke M. DiGuiseppi C. Pratap S. Wentz R. Kwan I. Increasing Response rates to postal questionnaires: systematic review. British Medical Journal. 2002
Goga AE and Muhe LM. Global challenges with scale up of the Integrated Management of Childhood Illness strategy: results of multi-country survey. BMC Public Health 2011, 11: 503.
http://www.biomedcentral.com/1471-2458/11/503
Gouws E, Bryce J, Habicht JP, Amaral J, Pariyo G, Schellenberg JA and Fontaine O.
Improving anti-microbial use among health workers in first level facilities: Results from Multi-Country, Evaluation of Integrated Management of Childhood Illness strategy. Bulletin of World Health Organization. July 2004; 82(7): 509-515.
Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bulletin of the World Health Organization. 1997;75(Suppl 1):7-24
Hamer C, Kvatum K, Jeffries D, Allen S. Detection of severe protein-energymalnutrition by nurses in The Gambia. Archives of Disease in Childhood. 2004;89(2):181-184.
Hill Z, Kirkwood B, Edmond K. Family and community practices that promote child survival, growth and development: A review of the evidence. World Health Organization Geneva 2004.
(Accessed on 22.3.2012). Available from:
http://whqlibdoc.who.int/publications/2004/9241591501.pdf
IPEN-IMNCI Study Phase 1 (2006-2007). Evaluation of Integrated Management of Neonatal and Childhood Illness (IMNCI) Program in India: An IPEN Study. (Accessed on 24.03. 2014).
Available from:
http://inclentrust.org/inclen/uploadedbyfck/file/complete%20Project/Evaluation%20of%20Inte grated%20Management%20of%20Neonatal%20and%20Childhood%20Illness.pdf
Kellerman SE and Herold J. Physician response to surveys. a review of the literature.
American Journal of Preventive Medicine 2001;20 (1): 61–67
Khan RA, Knowledge of clinical case management of IMNCI among trained and untrained primary health care personnel in two districts of province Punjab in Pakistan. University of Tampere Medical School Finland. September 2009.
Kumar D, Aggarwal AK, Kumar R. The effect of interrupted 5-day training on Integrated Management of Neonatal and Childhood Illness on knowledge and skills of primary health care workers. Health Policy Plan 2009 Mar;24(2):94-100
Lambrechts T, Bryce J and Orinda V. Integrated Management of Childhood Illness: A summary of first experiences. Bulletin of World Health Organization 1999 77(7), 582-594.
Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths; when? Where? Why? The Lancet 2005. Volume 365, Issue 9462,5-11 March 2005, pages 891-900
Muller O and Krawinkel M. Malnutrition and health in developing countries, Canadian Medical Association Journal (CMAJ) August 2, 2005 volume 173, no. 3: 279-286.
Mushi AK, Schellenberg JR, Mpondo H and Lengeler C. Targeted subsidy for malaria control with treated nets using a discount voucher system in Tanzania. Health Policy and
Planning(2003)18 (2):163-171.
Naeye RL. Causes of perinatal mortality in the US. Collaborative perinatal project, The Journal of the American Medical Association ( JAMA) 1977; 238 (3) 228-229.
Paranhos VD, Pina JC, Mello DF. Integrated Management of Childhood Illness With the Focus on Caregivers: An Integrative Literature Review. Rev. Latino-Am. Enfermagem 2011, Jan-Feb. 91(1): 203-211.
Pariyo GW, Gouws E, Bryce J, Burnham G (2005) Improving facility-based care for sick children in Uganda: Training is not enough. Health Policy and Planning 2005; December 20 (Suppl 1): 158–168.
Patwari AK and Raina N. Integrated Management of Childhood Illness (IMCI): A Robust Strategy. Indian Journal of Pediatrics. 2002 Jan; 69 (1): 41-48.
Pulakka A. WHAT, WHEN AND FROM WHOM? Healthcare providers, Views to infectious
Pulakka A. WHAT, WHEN AND FROM WHOM? Healthcare providers, Views to infectious