KNOWLEDGE OF INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS AMONG DOCTORS AND NURSES - STUDY FROM SABYA AND TATHLEETH SECTORS OF KINGDOM OF SAUDI ARABIA
Muhammad Safdar Master’s thesis Public Health School of Medicine
Faculty of Health Sciences University of Eastern Finland September 2017
UNIVERSITY OF EASTERN FINLAND, Faculty of Health Sciences Public health
SAFDAR MUHAMMAD: Knowledge of Integrated Management of Neonatal and Childhood Illness among doctors and nurses - Study from Sabya and Tathleeth sectors of Kingdom of Saudi Arabia.
Master’s thesis, 69 pages, 2 appendices
Supervisors: Sohaib Khan, MBBS. RMP. MPH. PhD. Maria Semenova MD. MPH September 2017
Key Words: IMCI, IMNCI, Case Management, Saudi Arabia, Knowledge Score.
KNOWLEDGE OF INTEGRATED MANAGEMENT OF NEONATAL AND
CHILDHOOD ILLNESS AMONG DOCTORS AND NURSES-STUDY FROM SABYA AND TATHLEETH SECTORS OF KINGDOM OF SAUDI ARABIA
The main global health issue is to lower the neonatal and childhood morbidity and deaths.
About 10 million under 5 years of age children die before to achieve their 5th birthday every year. In Kingdom of Saudi Arabia less than 5 mortality rate is 18 per 1000 live births. To improve the health of children, Kingdom of Saudi Arabia has adopted and implemented IMNCI strategy (Integrated Management of Neonatal and Childhood Illness) in 2000
Questionnaire based cross sectional survey was done in two health sectors of Saudi Arabia to assess the knowledge of IMNCI strategy regarding clinical case management among primary health care professionals in Sabya and Tathleeth sectors of Kingdom of Saudi Arabia (99 participants, response rate 43.2%).
There was no statistically significant difference in knowledge scores between physicians (µ=7.4) and nurses (µ=6.5), (p=0.07). No difference in knowledge score was found between Sabya (µ=7.0) and Tathleeth (µ =7.0), (p=0.971). However, participants trained during
studies scored much higher (µ=9.09) than untrained (µ=6.13), (p≤ 0.001). The graduates from Sudan scored higher (µ= 8.19) than graduates from other countries (p = 0.02). Participants graduated up to 1980 were scored higher (µ = 8.45), than the participants having graduation after 1980 (p=0.02)
Study results indicate that IMNCI training in clinical case management improves knowledge of healthcare professionals. Eleven days training in case management of IMNCI program may help to improve knowledge among pediatric personnel and further decrease deaths and illnesses in less than 5 years of age children. Further research may reveal practical application of knowledge of clinical case management to enhance the health of less than 5 years children and their survival.
ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome AMREF African Medical Research Foundation ARI Acute Respiratory Infection
BCG Bacillus Calmette-Guerin BMJ British Medical Journal CAH Child and Adolescent Health CCS Country Cooperation Strategy CHD Child Health Development DPT Diphtheria Pertussis Tetanus
EMRO Eastern Mediterranean Regional Office HIV Human Immunodeficiency Virus
IMCI Integrated Management of Childhood Illness
IMNCI Integrated Management of Neonatal and Childhood Illness IPEN IndianCLEN Program Evaluation Network
KSA Kingdom of Saudi Arabia
MCE Multi Country Evaluation MDG Millennium Development Goal
OPV Oral Polio Vaccine
PHCC Primary Health Care Centre
SD Standard Deviation
UNDP United Nation’s Development Project UNICEF United Nation’s Children Fund WHO World Health Organization
ACKNOWLEDGEMENTS
I would like to express my sincere gratitude to my supervisors Dr. Sohaib Khan and Maria Semenova from the institute of Public Health and Clinical Nutrition, Faculty of Health Sciences and University of Eastern Finland for their valued guidance and support. Their motivation and constant guidance gave me self-reliance to complete this research. I highly appreciate his enlightening and productive inputs throughout the research work and manuscript writing. I would like to express my gratitude to Director School of Public Health and Clinical Nutrition Professor Jussi Kuahanen for valuable coaching throughout the program and precious support afterwards. I am also thankful to Technical Medical Director Sector Sabya Dr. Midhat Sabbah- el- Din and Director Sector Sabya Abdulliha Fai Asiri for their valuable cooperation in data collection
I highly appreciate my co-researcher Dr. Rizwan Ahmad Khan who extended his untiring efforts and unconditional support from data collection to manuscript writing. His readiness to guide, coach and facilitate me throughout the process of thesis especially for data management and statistical data analysis was commendable.
I would like to thank directors of Tathleeth and Sabya sectors for their cooperation and facilitation in data collection. I am also thankful to all doctors and nurses who contributed their time and effort to take part in this survey.
Finally, words alone cannot express the thanks I owe to my wife for her constant encouragement and family for all their love and concern.
Kuopio, December 2016 Dr. Muhammad Safdar
Contents 1.
INTRODUCTION………..Err or! Bookmark not defined.
2. LITERATURE REVIEW………3
2.1. Common mortality factors and co-factors in under-5 children………3
2.1.1. Pneumonia...3
2.1.2. Diarrhea………Error! Bookmark not defined. 2.1.3. Malaria……….4
2.1.4. Measles………5
2.1.5. Malnutrition……….5
2.1.6. Perinatal Deaths………6
2.2. Need for IMNCI strategy……….6
2.3. Objectives of IMNCI strategy………7
2.4. Components of IMNCI strategy……….8
2.4.1. Enhancing the health worker skills and performance………8
2.4.2. Upgrading of Health System………9
2.4.3. Promoting the Family and Community Practices………9
2.5. Implementation of IMNCI strategy………12
2.5.1 Introduction Phase……….12
2.5.2. Early Implementation Phase………..133
2.5.3. Expansion Phase……….13
2.6. Evaluation of IMNCI strategy………144
2.7. IMNCI strategy in Kingdom of Saudi Arabia………15
2.8. IMNCI Knowledge assessment in other studies………..166
2.9 Reason for doing the study………..17
3. STUDY AIMS………17
4. STUDY SUBJECTS AND METHODS………..18
4.1. Study Setting………18
4.2 Study population and participants……….18
4.2.1. Sample size calculation and its justification………...19
4.3 Methodology used in study………19
4.3.1 Survey questionnaire………19
4.3.2 Survey……….20
4.4 Research team……….211
4.5 Data management………21
4.6 Ethical Issues of the study………21
4.7 Funding for the Study……….21
4.8 Analytical approach……….222
4.8.1 Outcome measures……….Error! Bookmark not defined.2 4.8.2 Variables in analysis……….22
4.8.3 Statistical analysis……….22
5. RESULTS………22
5.1 Background of study participants in two sectors characteristics………22
5.2. Comparison of means score between study groups………Error! Bookmark not defined. 5.3. Relationship between variables - Univariate ANOVA……….………..27
5.4. Comparison between groups-one way ANOVA and Post Hoc test………30
6. DISCUSSION………377
6.1. Findings of the study………377
6.2 Validity and reliability of the study………388
6.2.1 Response rate
issues………388
6.2.2. Internal Validity and Bias control………..39
6.2.3. External validity……….39...39
6.3. Correlation with previous studies……….40
6.4. Limitations of the present study………..41
6.4.1.Questionnaire and its Limitations ... ...41
6.4.2. Recall issues...41
6.4.3. Sample collection and its Limitations ……….41
6.5. Public health implications of study...42
6.6 Future research significance………..42
7. CONCLUSIONS AND RECOMMENDATIONS……….43
8. REFERENCES……….433
Appendix 1 Survey Questionnaire………..55
Appendix 2 Univariate Analysis of Variance Tables………..60
1. INTRODUCTION
Global under-five mortality rate was around 12.7 million deaths per year in 1990. It decreased to about 5.9 million deaths per year in 2015. In 2011, daily death rate of children was almost 16000. Globally, younger than 5 year deaths in children has reduced by 53% i.e. from 91 (89, 92) per 1000 live births in 1990 to 43(41, 46) in 2015. Forty percent of fewer than 5 mortalities happened in the neonatal period that accounted about 2.7(2.5, 2.9) million deaths in 2015 (UNICEF 2015). The first week of life is the most crucial and more than half of neonatal causalities happen in the same week (Lawn et al. 2005). Majority of the child mortalities occur in low income countries, rural regions poor and less educated families (Black et al. 2003, WHO 2015) `
Saudi Arabia is the largest country of Middle East and the second largest Arab state in the world.
In KSA below-5 death rate in children was 44 (36-55) per thousand live births in 1990 which dropped to 15(9-26) per 1000 live births in 2015. In KSA, the neonatal mortality rate was 22 per thousand live births in 1990 and reduced to 8 per 1000 live births in 2015. The infant mortality rate was about 36 per 1000 live births in 1999 and decreased to 13 per 1000 live births in 2015 (UNICEF 2015).
The Millennium Development Goal (MDG) 4 promises to lower the below-five mortality rate by two-thirds from 1990 to 2015. For KSA, target of MDG 4 is 15 deaths per 1000 live births by 2015 as compared to 44 deaths per 1000 live births in 1990 (UNICEF 2015). In KSA, the reduction achieved so far is seemed to be on track to achieve MDG 4 by the year 2015.
According to WHO, MDG targets have achieved satisfactory and under five child mortality have reduced to 53% at the end of 2015 globally. The target was 67% since 1997. In Eastern Mediterranean Region, the under-five child mortality has reduced to 48% since 1990 to 2015(WHO 2015).
Keeping in view the multiple and mixed risk factors of childhood morbidity and mortality, World Health Organization launched a strategy named Integrated Management of Childhood Illness (IMCI) in mid-1990. Later the strategy included neonates as well and modified as (IMNCI) Integrated Management of Neonatal and Childhood Illness strategy (WHO 2003).IMNCI strategy was adopted by many countries to enhance healthy growth of children and used as case management strategy in primary level healthcare facilities (WHO 2003).
KSA also adopted IMNCI strategy to raise the healthy growth and development of their below 5 years of age children.KSA seems to be on track to achieve the child health target in spite of this healthcare personnel need to have better and updated knowledge of key issues in child health care and their management to provide continuous and appropriate care to them. This questionnaire survey was done in two sectors of KSA at primary level healthcare facilities to evaluate and compare the knowledge of clinical case management of IMNCI among key healthcare providers.
2. LITERATURE REVIEW
This literature review mainly describes IMNCI strategy (components, objectives, implementation and evaluation), need for IMNCI strategy in the management of deadly childhood illnesses, common childhood diseases and co-factors of illness and death in less than 5 years old children., As the study was done in KSA (Kingdom of Saudi Arabia), so the implementation of IMNCI in Saudi Arabia is considered
2.1. Common mortality factors and co-factors in under-5 children
Under 5 children especially neonates are more at risk for diseases than adults. Globally, there are five common diseases which cause death in below 5 years age children especially in low income countries such as pneumonia, diarrhea, measles, malaria, malnutrition or combination of all or some of these illnesses (Arifeen et al. 2005, Gove et al. 1997, UNICEF 2008, UNICEF 2015, Weber et al. 1997). The major risk co- factors for infectious diseases are poverty, unhygienic living conditions, impure water, illiteracy and lack of quality health care (Zaidi et al. 2004).
Food insecurity, early and multiple pregnancies, low literacy rate among females, discrimination and lack of approach to proper health and nutritional facilities due to poverty and political set up are unusual co-factors which contribute towards child death (UNICEF 2008).
Infections such as diarrhea, pneumonia, tetanus and sepsis contribute up to 32% of deaths of newborn babies, 24% expiries are due to prematurity related problems, asphyxia and injuries during child birth and injuries contribute to about 29%. Low birth weight is another co-factor in neonatal deaths. Neonatal infections also contribute in neonatal deaths and common factors for neonatal infections are poor antenatal care, low- trained birth attendants, dirty delivery practices, low birth weight babies, poor control of infections, less use of exclusive breast- feeding and poor immunization against tetanus among mothers (Zaidi et al. 2004).
2.1.1. Pneumonia
Among acute respiratory infections, globally the single prominent cause of severe morbidity and mortality between neonates and children of less than five is pneumonia. Pneumonia caused about 920136 deaths in under-5 children worldwide in 2015and contributes about 16% of all child deaths globally. It causes illness in children and families anywhere but sub-Saharan Africa and South Asia are the major prevalent territories (WHO 2016a). The respiratory infections are
caused by viruses, bacteria and fungi. The most common bacterial organisms causing pneumonia in neonates and children are Streptococcus pneumoniae and Haemophilus influenzae (WHO 2005).
According to IMNCI guidelines, pneumonia is assessed and classified as severe pneumonia, pneumonia or no pneumonia. Pneumonia can be managed at community level with the support of properly trained community health facilitators. The best way to treat and reduce pneumonia at community level is by using standard antibiotics such as amoxicillin along with preventive measures. In this regard, important preventive measures are timely vaccination, exclusive breast- feeding and energy rich feed after the age of six months (WHO 2005).
2.1.2. Diarrhea
Diarrhea is defined as “the passage of three or more loose or liquid stools per day”. Diarrhea is considered as second major cause of mortality in under-5 years children. Diarrhea is a symptom of waterborne diseases produced by bacteria, viruses and parasites. The prime causative organisms are rotavirus and Escherichia coli. About 760000 children die per year due to diarrheal diseases (WHO 2015). Children under 2 years of age are mostly affected by diarrhea which most often leads to malnutrition. Diarrhea usually affects more to infants of less than 6 months age fed by cow milk and infant formulas (WHO 2005). The child having diarrhea must also be examined for dysentery by observing blood in stool (WHO 2008).
Malnutrition, unhygienic home environment, poor sanitation, open defecation, lack of vaccination and poor basic health facilities are major elements of danger for deaths due to diarrhea. All diarrheal diseases are preventable by exclusive breast feeding, healthy nutrition, timely vaccination, soap hand washing, safe water, improving sanitation, use of ORS and Zinc supplementation (UNICEF 2012).
2.1.3. Malaria
About more than one million causalities are occurred due to malaria every year thus contributing about 8% childhood deaths a year. Globally, deaths from malaria have reduced about 25 percent since 2000. In 2010, worldwide deaths due to malaria were about 655000 and about 86% of them were among the younger than 5 years old children (WHO 2011). In 2015, nearly 214 million malaria cases were reported and almost 438000 deaths occurred in 100 countries of
world. Most of these deaths are in less than five years age children especially in sub- Saharan Africa where burden of malarial disease is the highest in the world (WHO 2015)
Treated mosquito nets provide good protection against malaria in the regions of “intense transmission Plasmodium Falciparum” (Mushi et al. 2003). In sub-Saharan Africa, about 40%
deaths among below 5 years of age children are due to malaria disease along with pneumonia because of overlap of symptoms. As the symptoms of malaria and pneumonia overlap, so management based on IMNCI strategy includes provision of antibiotics and anti-malarial drugs together (Ukwaja et al. 2011).
2.1.4. Measles
This is the fourth common mortality cause in less than 5 years old children. Before the widespread use of vaccination against measles, there were about 2.6 million deaths yearly. In 1999, out of 10.5 million under-5 year old child deaths in developing countries about 8% were due to measles (WHO 2001). In 2005, worldwide 345000 people died of measles and among them 90% were children of less than 5 years. In 2007, the global burden of this highly contagious disease was 4% among younger than 5 years old children (UNICEF 2008). Despite the availability of safe and low cost vaccine, there were 114900 deaths in less than 5 year age children globally in 2014 (WHO 2016b). The major signs of measles are fever and body rash. 6 months to two years is the most vulnerable period for measles in children. The complications of measles are diarrhea, pneumonia, mouth ulcers, ear problem, eye infections and acute encephalitis. It’s a vaccine preventable disease (WHO 2005).
2.1.5. Malnutrition
Malnutrition or under – nutrition is a common element of illness and deaths in less than 5 years old children globally. In 2000, about 150 million children were malnourished and about to half of child deaths happen in the under developed and low income countries related to secondary effects of malnutrition (Hamer et al. 2004). Malnutrition has two components, protein energy malnutrition and lack of micronutrients. The major burden of malnutrition is in under develop countries specially South Asia and sub-Saharan Africa. Malnutrition is directly involved in about 300,000 deaths annually and causes about 150,000 casualties in below five babies indirectly in low income countries (Muller and Krawinkel 2005). In 2015, 93 million under-five children are
suffered from secondary effects of malnutrition and 45% of deaths in children are directly related to malnutrition (WHO 2015).
Child malnutrition is considered as major public health measure for assessing nutritional health situation in the community. Childhood malnutrition is a good indicator for assessing development regarding Millennium Development Goals (de Onis et al. 2004). Lack of breastfeeding, low quality food, lack of access to highly nutritious food and deficiency of zinc, vitamin A and iodine like micronutrients are common contributing factors to malnutrition.
Infections like diarrhea, pneumonia, measles and malaria also contribute to malnutrition. Early, exclusive and continued breast feeding along with complementary and micronutrients rich feeding after the age of 6 months can reduce the burden of under nutrition in children (UNICEF 2012).
2.1.6. Perinatal Deaths
Perinatal deaths contribute up to 37% in neonatal deaths globally. In developing countries share of peri-natal deaths is up to 18% in the child deaths occurring in less than five years old children(WHO 2005). In the year 2000, globally there were 6.3 million peri-natal deaths and 98% of these deaths were in developing countries. About 2 million peri-natal deaths occur during child birth. HIV/AIDS and other factors contribute up to 12% of under - 5 child deaths (Muller and Krawinkel 2005). There are many causes of peri-natal deaths such as infection of amniotic fluid, placental abruption, early rupture of membranes, congenital problems and infarcts in the placenta. Home deliveries also contribute towards peri-natal deaths (Naeye 1977).
2.2. Need for IMNCI strategy
Keeping in view global child health challenges, WHO, UNICEF and collaborators came up and developed an integrated approach known as “Integrated Management of Childhood Illness strategy”. After its introduction in 1995, in year 2000 the strategy included also newborns upto 28 days and retitled as “Integrated Management of Neonatal and Childhood Illness (IMNCI)”.
So the IMNCI is a more comprehensively extended form of IMCI strategy since 2000 (WHO 2003).
Integrated management of childhood and neonatal illness (IMNCI) program is broad and covers the aspects of health promotion, immunization, nutrition, disease prevention along with
treatment of diseases (WHO 2003). Thus, IMNCI strategy is a comprehensive integrated approach which combines adequate nutrition, immunization and updated management of common childhood morbidities such as malaria, diarrhea, pneumonia, ear problems and anemia (Lambrechts et al. 1999).
IMNCI strategy was introduced to support in achieving fourth millennium development goal (MGD4) especially in low income countries. About 100 countries adopted this strategy between 1996 and 2011 (Goga and Muhe 2011).
2.3. Objectives of IMNCI strategy
Under-5 child mortality is a complex child health issue and needs both curative and preventive interventions to reduce it. Most of the diseases which are responsible for deaths in less than 5 years old children are preventable (IPEN 2006).
The strategy has multiple objectives such as
It aims to improve home care and health systems, to educate health care workers to inhibit, decrease and treat vital diseases in an active and integrated manner (WHO 1999b, Gouws et al. 2004).
To improve development and healthy growth by reducing frequency of illnesses and deaths in under-5 babies (WHO 2005)
To provide preventive and curative measures for the principal childhood illnesses both at health facilities and at home. So the IMNCI strategy provides guidelines for dealing child diseases at home and in the health centers (WHO 1999d).
To decrease deaths in children below 5 years old and reduce the burden of infectious diseases like measles, malaria, tuberculosis, pneumonia, diarrhea, meningitis, intestinal parasites and resolve nutritional problems (Paranhos et al. 2011).
To use the evidence based syndromic approach to assess the illness of child, severity of child problem and take action for the treatment of ill child such as treat at home, manage in the health facility and / or referral to higher centers (WHO 2003).
To ensure the active participation of family persons and society in the health care system.
Parents are motivated to involve in the health and growth of their children (WHO 2003).
2.4. Components of IMNCI strategy
IMNCI strategy focuses on three major elements.
Enhancing the case management skills of primary level health facilitators.
Upgrading the health systems to support IMNCI program
Promoting the family and community practices.
2.4.1. Enhancing the health worker skills and performance
This component of IMNCI strategy consists of training of doctors; nurses and other health workers during or before service to familiarize them with signs and symptoms of sick child and to manage their illness in an integrated way. The training is based on case management guidelines, so that the health care givers will be able to take complete history, do proper examination, make correct diagnosis, classify common childhood illnesses, advice suitable treatment and counsel the parents for better child health and outcome. The IMNCI training also guides the health professionals to identify anemia and under-nutrition, to check the vaccination status and how to communicate with mother or care giver (WHO 2004,Gouws et al. 2004).
The training of health providers in “IMNCI Case Management” at primary level health facilities is important for improvement in their clinical skills. The 11 day training program is mainly based on practical methods and hands on experience. Most of the training time is used for clinical practice where trainee health workers go to the different clinics and supervised spots to practice clinical skills and get feedback from their instructors. In the class rooms, the lectures are delivered with the help of charts / photographs, videos, readings and other supportive training materials (Lamberchts et al. 1999).IMNCI case management training skills program combines both curative and preventive care along with training in using special case management algorithms is provided (Victora et al.2006).
IMNCI case management training program demands from trainees that they should acquire sound knowledge and skills “to assess, classify and treat sick children” less than 5 years of age and also to counsel the parents. Regarding assessment, first of all, the entire health care givers note the “danger signs such as convulsions, lethargy, unconsciousness, vomit everything and unable to drink or breastfeed”. They inquire about common clinical features like cough with shortness of breath, loose motions, high temperature and ear infection. They also ask from care
givers about the nutrition, vaccination and other health issues. After the assessment, the health care provider classifies the baby with the help of classification chart. Then the health care giver decides a comprehensive treatment for the sick child and if the child needs immediate referral, then health care provide gives a first dose of medicine at the health facility and refers the sick child to hospital. The trained health worker also counsel the mother regarding how to give oral medicines, continue feed during sickness, vaccination, breast feeding and follow up care if necessary (Weber et al. 1997, AMREF 2007).
2.4.2. Upgrading of Health System
This component of IMNCI strategy focuses on strengthening of healthcare system through essential drug availability, availability of adequate equipments, effective organization and supervision, referral system, policy for health information and health reforms (Patwari and Raina 2002).
For proper management of childhood diseases, health system reforms like supervision of managers, provision of trained health providers and improvement of work at health facilities are essential (WHO 2005). So the purpose of improvement in health systems is to strengthen the health facilities. All health facilities should have necessary supplies, equipments, special drugs for IMNCI case management, supplies for vaccination of all children and about 60% of working staff should have IMNCI training (WHO 1999a).
2.4.3. Promoting Family and Community Practices
This component of IMNCI strategy focuses on community and family practices related to growth and health of children. The key issues which are focused in this component are exclusive breastfeeding, age specific childhood nutrition, personal hygiene, micronutrients, vaccination, insecticide treated nets, mental and social development, adequate nutrition during sickness, treatment of common infections at home, antenatal care, care seeking practices and compliance(WHO 2004,Victora et al. 2006).
Care seeking is a primary response of family for any sickness. At caregiver level, late recognition of child disease or illness delays treatment and thus child health outcome. To enhance timely family reaction, research and investigating methods should be adopted to improve the skills for the identification of serious kind of signs and symptoms of childhood illnesses by the caregivers in the home. Counseling of mothers is an important part of clinical
case management of IMNCI strategy. Mothers must obey the advices of primary health worker regarding follow up and referral instructions (WHO 1999c).
This component of IMNCI strategy is also known as household and community IMNCI (HH/C IMNCI). This component was first launched in September 1997 at IMCI Global Review and Coordination Meeting (Lambrechts et al. 1999). In June 2000 in Durban, WHO and UNICEF prepared 16 “Key Family Practices”. The basic purpose of these family and society practices is to improve child growth and progress. These key practices have been divided into four groups (Winch et al. 2002).
THE FIRST GROUP focuses practices for physical growth and mental development. The key issues raised in this group are exclusive breastfeeding (EBF) for 6 months, provision of energy rich complementary food after six months, sufficient amount of micronutrients in diet and special care for the mental and social development of child. Breast milk is the source of all essential nutrients which are needed by infants up to age of six months (Hill et al. 2004).
Continuous breastfeeding for two years of age and energetic, fresh, nutrient rich complementary feeding from 6 months of age was also advocated along with essential nutrients such as iron and vitamin A. Taking care of children’s needs and providing them with supporting environment for social well being and mental growth was also advocated (Winch et al. 2002).
THE SECOND GROUP focuses practices for disease prevention. Immunization, hygienic environment, protection of children from malaria in endemic areas and care of HIV/AIDS affected children are the main practices included in this group. Thus children should have full course of vaccination such as BCG, DPT, OPV and measles up to one year. Personal hygiene particularly washing of hands after defecation, before giving food to children, before food preparation and proper disposal of feces is essential for prevention of diseases. Ensuring provision of bed nets was advocated for children living in malaria endemic regions. Supportive behavior was advocated towards children who born to HIV/AIDS affected parents (Winch et al.
2002).
THE THIRD GROUP focuses practices for appropriate home care. The major practices related to this group are continuation of feed and fluid to children during illness, provision of
appropriate home treatment for infections, provision of safe home environment to avoid injuries and accidents, proper measures to avoid child abuse and neglect, and ensuring that other family members take interest in the healthy growth of child and family. It advocates that if a child is sick, continue good feed and fluids specially the breast milk which work well against disease. It further advocates management of minor infections at home (Winch et al. 2002).
THE FOURTH GROUP comprised of practices regarding care seeking for sick child. When a child is sick and needs treatment outside home, then treatment should be taken from qualified health worker and in all situations such as treatment, referral and follow up advice of health provider must be followed. Another important practice in this group is proper antenatal care for the pregnant women with qualified health care facilitator, recommended doses of tetanus immunization and supportive behavior and cooperation from the family members during delivery, postpartum period and lactation (Winch et al. 2002).
Finally, WHO/UNICEF recommended 12 community and family practices in a meeting held in 2004, which are considered essential for the growth, development, survival, reduction in illnesses and sound health of young kids less than 5 years of age (Hill et al. 2004). These practices are:
All children should complete the basic vaccination before the first birthday such as BCG, DPT, OPV and measles
Exclusive breastfeeding (EBF) up to six months
At the age of six months, start the fresh and energy rich complementary food and continue the breastfeeding till two years or more
Be sure that the children get proper amount of micro-nutrients especially zinc, iron and vitamin A through diet or in the form of supplementation
Wash hands properly after defecation, before food preparation and before serving food to children. Safe dispose of children’s feces is essential
Assure the use of treated bed nets by children in malaria endemic territories.
During sickness of children, continue food and fluids including breastfeeding
For minor infections, treat the sick at home
In case of a sick child, go to qualified health care giver if there is need of advice outside the home
Obey the health professional’s advice about management, referral and follow-up of sick child
Provide supportive environment for the better mental and social development of children
Antenatal care is important for pregnant ladies. So ensure proper antenatal care for a pregnant woman such as four antenatal visits with qualified health provider, recommended dose of tetanus toxoid and support from family for delivery, lactation and postnatal period (WHO 2004).
2.5. Implementation of IMNCI strategy
Implementation of IMNCI strategy consists of three phases, 1) Introductory phase
2) Early implementation phase 3) Expansion phase
2.5.1 Introduction Phase
IMNCI strategy was introduced first time in 1996 and 100 countries have adopted it since then.
In the introduction phase, meetings were held in different countries for orientation, training of health workers by trained persons, to make a plan for implementation of IMNCI and the involvement of government to move forward with IMNCI strategy (Victora et al. 2006). The introduction phase of IMNCI program also included the health policy guidelines and interventions in the primary health facilities which are revised for the effective implementation.
The introduction of IMNCI program gives an opportunity to many countries to revise their health policies and services. The important recommendations in the introduction phase at country level are to involve the senior health officers, child specialists, donors and other stake holders, so that they all are well aware of IMNCI strategy and make a decision to move forward.
Participation of ministry of health officials and child specialists to plan for IMNCI training course and adaptation process is essential. Clinical case management training course and adaptations are important to enhance this program. Involvement of major donors, interested
partner agencies and senior MOH officials for better IMNCI planning and implementation is also essential (WHO 1999d).
2.5.2. Early Implementation Phase
In this phase, ministry of health officials plan and prepare other health related workers for implementation of IMCI program and its activities in limited regions of country. This experience of implementation will be used for future planning (Lambrechts et al.1999). According to WHO guidelines, districts are selected for the early application of IMNCI program according to specific criteria such as proper approach to central level staff, motivated and cooperative personals at district level facilities, training place, appropriate drug availability, facility of referral care, funds for IMNCI program from some donor foundation, availability of feeding methods for the small children and diary for common or local language (Victora et al. 2006).
The main aim of this phase is the improvement of health care in primary health centers and development of clinical case management guidelines. This is possible by enhancing health systems and adaptation of interventions to improve the community and family practices. There is need of national action plan for IMCI early implementation phase. The steps involved in national action plan prepared by ministry of health are to develop a national plan for early implementation, adapt the generic IMCI guidelines and training material, training of health workers, enhance district plans for early implementation, implement interventions to improve community and family practices, monitoring and review processes for this IMCI early implementation phase (WHO 1999a).
2.5.3. Expansion Phase
Expansion phase includes attempts to enhance the interferences and cures which were started in the early application phase and to widen the scope of interferences inside country. In this phase, efforts are made to solve the problems which are identified after the phase of early implementation and policies are made to spread this program with quality maintenance (Lambrechts et al. 1999).
Other aims of this phase are to improve the drug availability, to empower the district level capacity, to develop management at primary health centers, proper monitoring, documentation, evaluation and its implementation (WHO 1999d).
2.6. Evaluation of IMNCI strategy
“The Multi-country evaluation of IMNCI effectiveness, cost and Impact (MCE-IMCI)” is a worldwide evaluation of IMNCI strategy which was planned in 1997 with the help of department of Child and Adolescent Health (CAH) of WHO in the countries who adopted the IMNCI strategy initially (Bryce et al. 2005). MCE-IMCI program was supported by Bill and Melinda Gates Foundation, the United States agency for international development and other partners.
Multi-country Evaluation (MCE) program followed the guidance from several external technical advisers which had special experience in epidemiology, public health, public health nutrition and mortality reasoning in children below the age of five years (WHO 2002).
The major aim of multi-country evaluation (MCE) was to know the effect of IMCI strategy on child health improvement and cost-effectiveness. The other objective of MCE was to find the ways so that the integrated child health care can be delivered efficiently to the children of poor families and the experience from these objectives and interventions should be delivered at vast level in the country for better child health, development and survival (WHO 2002). Other important goals of Multi-Country Evaluation (MCE) were to maintain the record of impact of IMCI interventions on health system, health care providers and community behavior for the improvement of child health programs (Bryce et al. 2004).
This multi-country evaluation of integrated management of childhood illness effectiveness, cost and impact (MCE-IMCI) program was initially done in Bangladesh, Peru, Brazil, United Republic of Tanzania and Uganda (Gouws et al. 2004). Recommendations of this evaluation are as follows:
Integrated management Neonatal and childhood illness (IMNCI) enhances the efficiency of health care providers and improves the quality of care.
Proper implementation of IMNCI program decreases the death rate in under - five children and enhances their nutritional status.
IMNCI strategy is economical, cost effective and reduces the cost in managing sick children.
Child development strategies need to enhance the actions for the improvement in community and family practices and behavior.
During the implementation of child development programs, actions should be taken to empower the health system for better care.
To achieve meaningful decrease in under - five child morbidity and mortality, it’s essential to enhance the coverage of IMNCI strategy.
It was found that sick children who attended health facilities where IMNCI program was implemented were better assessed and took quality care treatment than those children who attended health care centers where no staff was trained for IMNCI strategy (WHO 2001). A report of Millennium Development Goals says that after the implementation of IMNCI strategy, there was about two third reduction in mortality among children less than five years of age in 2008 than 1990 (UNICEF 2008). So the IMNCI strategy seems to have a definite role in decreasing below five illness and deaths and helps in improvement of child health and nutrition.
2.7. IMNCI strategy in Kingdom of Saudi Arabia
Saudi Arabia is an oil resource rich and a fast developing country with an area of 2.15 million/km2. In the last 30-40 years, there is reasonable development in socioeconomic sector such as health, education, housing and environment. There are new well equipped hospitals, teaching institutions and tourism facilities throughout the country (WHO-EMRO 2013)
KSA has sound health system with free medical services and has many well equipped primary, secondary and tertiary care health facilities in most parts of the country. Although health indicators are satisfactory but not up to mark as compared to developed world. Neonatal mortality rate was 22 per thousand live births in 1990 and reduced to 8 per 1000 live births in 2015 (UNICEF 2015).According to studies in Aseer and other regions of KSA, the important causes of neonatal deaths are congenital malformations, low birth weight, infection, prematurity and birth asphyxia (Bassuni et al. 1997). The infant mortality rate was about 36 per 1000 live births in 1999 and decreased to 13 per 1000 live births in 2015. Under-5 mortality rate in Saudi Arabia was 44 (uncertainty interval 36-55) per 1000 live births in 1990 which decreased to 15 (uncertainty interval 9-26) per 1000 live births in 2015 (UNICEF 2015).
In Kingdom of Saudi Arabia IMNCI program was introduced in 2000 by the National IMNCI task force made by ministry of health. First orientation meeting of National IMNCI task force
was held in October 2000 and planning workshop was arranged along with meeting. Years 2003 to 2005 were the years of early implementation phase. Adaptation workshop of IMNCI planning and task force was held in May 2003 in which “adaptation of IMNCI clinical guidelines” and other requirements were completed. First 11 day clinical case management of IMNCI course was held from 27 February to 10 March 2005 at central level for doctors. In the beginning, seven doctors were also trained in Egypt (WHO – EMRO 2005).
There is no data available on expansion phase of IMNCI strategy in Kingdom of Saudi Arabia.
2.8. IMNCI Knowledge assessment in other studies
In high child mortality countries, many investigators have studied and evaluated knowledge and performance of healthcare providers regarding clinical case management of IMNCI. Differences have beennoted among the comparison groups with respect to knowledge and performance.
Untrained personnel tend to have poorer knowledge and performance than trained (Armstrong et al. 2004). Kumar et al has also reported statistically significant improvement in average knowledge among primary healthcare workers after IMNCI training (Kumar et al. 2009). One study conducted in province Punjab of Pakistan showed that, on knowledge scale, trained health care personnel were much better than untrained (9.7 vs. 5.1; p=<0.001) (Khan 2009). Another survey in tertiary care hospitals of Karachi Pakistan did not find any difference in knowledge among postgraduate trainees, resident medical officers and medical offices of hence concluded that there are gaps in knowledge and practices of trained doctors regarding management according to IMNCI guidelines (Amin et al. 2015).
A study was conducted among nurses in Cape Town to evaluate the change in quality of care provided to sick children as a result of the routine implementation of the IMCI intervention.
Results of study revealed improvement in quality of care after intervention; marked improvement in assessment of danger signs in sick children was noted (7% versus 72%), assessment of co-morbidity was improved (5.2 versus 8.2), rational prescription was much better (62% versus 84%), starting treatment in the clinic was increased (40% versus 70%).On the other hand, there was no change in the treatment of anemia, prescription of vitamin A and counseling of caregivers (Chopra et al. 2005).
A study on improving facility-based care for sick children among health care trainees was conducted to assess the effects of scaling-up Integrated Management of Neonatal and Childhood Illness (IMNCI) on the quality of care received by sick children in 10 districts of Uganda. The results showed that health workers trained in IMNCI were found to deliver significantly better care than untrained (Pariyo et al. 2005).
A study was conducted on enhancing the quality and efficiency of facility-based child health care through Integrated Management of Neonatal and Childhood Illness (IMNCI) program among auxiliary nurses providing care for sick children at first-level health facilities in Tanzania.
The results showed that IMNCI training improved the quality and efficiency of child health care relative to routine child health care in the study Districts (Bryce et al. 2005a).
2.9 Reason for doing the study
Neonatal and child health are hot global health subjects for last many years. Healthcare providers are supposed to have better and updated knowledge of childcare especially about clinical case management of IMNCI guidelines to provide better care to children in primary care setting.
As per knowledge of researcher there was no data available on knowledge of healthcare personnel about clinical case management of IMNCI in primary care in KSA before this study.
So this survey was designed to assess and compare the knowledge of key primary care providers i.e. doctors and nurses in two sectors of KSA to know the gaps.
3. STUDY AIMS
To our knowledge, first time a survey was conducted to investigate knowledge of clinical case management of IMNCI among primary healthcare professionals in Tathleeth and Sabya sectors of KSA. This study aimed to assess the knowledge of clinical case management of IMNCI among healthcare professionals especially doctors and nurses having different nationalities and working in two study sectors of KSA. The study further assessed self-reported IMNCI training status, nationality, level of qualification, country of qualification and knowledge score of
participants. The other purpose of the study was also to get an overview of knowledge of clinical case management of IMNCI between health care professionals in two study sectors of KSA which may help in planning future interventions to address neonatal and child health in KSA
Specific aims of the study were
1) To assess and compare the knowledge about clinical case management of IMNCI among physicians and nurses in two sectors of KSA.
2) To assess and compare the knowledge about clinical case management of IMNCI within healthcare workers in two sectors of KSA.
3) To assess the level of knowledge of clinical case management of IMNCI among trained and untrained healthcare professionals in two healthcare sectors of KSA.
4. STUDY SUBJECTS AND METHODS
This was a comparative questionnaire based cross-sectional survey done in two sectors of Kingdom of Saudi Arabia. Data collection was done from August 2011 to February 2012. The survey sectors were Sabya in Jizan region and Tathleeth in Bisha region of KSA.
4.1 Study setting
The study was carried out among doctors and nurses who were working in Sabya sector (Jizan region) and Tathleeth sector (Bisha region) in KSA during the survey period.
Sabya is an administrative unit of Jizan region. During the survey period, sector population was about 60,000 persons. Sabya Health Sector was working under Directorate of Health Affairs in Jizan, Ministry of Health KSA. There were twenty primary healthcare centers (PHCCs) in Sabya sector which were providing preventive and curative health care facilities in the catchment area.
Tathleeth is an administrative unit of Bisha region and mainly comprised of rural areas.
Tathleeth Health sector was working under Directorate of Health Affairs in Bisha, Ministry of Health KSA. During the survey period sector population was about 56,000 persons.Tathleeth sector was responsible for providing preventive and curative health care facilities in the catchment area through its 19 PHCCs.
4.2 Study population and participants
In the survey sectors, most of the primary health care centers had 1-3 doctors and 0-3 staff nurses. Some big centers had up to 4-6 doctors and 7-8 staff nurses. Doctors and staff nurses working in the survey sectors during the survey period were invited to participate in the survey.
The study population included all doctors and nurses working in PHCCs in the survey sectors during the survey period who met all the inclusion criteria.
During the survey period, 50 doctors and 96 staff nurses were serving the community in the Sabya sector along with other staff. Likewise, 45 doctors and 38 staff nurses were serving the community in the Tathleeth sector along with other staff (see Table 1). Participants were recruited through their respective sector directorate.
Table 1:Healthcare sectors and their healthcare facilities
SABYA N
TATHLEETH N
TOTAL N
PHCC’s 20 19 39
Doctors 50 45 95
Staff Nurses 96 38 134
Inclusion criteria for the respondents of the survey were as follows:
Doctors and staff nurses working in PHCCs in both sectors during survey period
Doctors and staff nurses who showed their willingness to participate in the study by receiving and accepting the survey questionnaire.
4.2.1. Sample size calculation
This was a convenience census survey conducted among doctors and nurses who were working in survey sectors during the period of survey.
4.3 Methodology used in the survey 4.3.1. Survey questionnaire
A semi-structured IMNCI guidelines based questionnaire, in English, was used as a study tool (Appendix – I). This questionnaire is a modified version of pre-tested questionnaire that was in use in province Punjab of Pakistan to assess the knowledge of the participants of 11 – day clinical case management of IMNCI training. A written permission was obtained from the co- researcher of this study to use his question with few modifications for this survey; he used it as his study tool in another survey in province Punjab of Pakistan in which he evaluated knowledge of clinical case management of IMNCI among trained and untrained healthcare providers (Khan, 2009).
There were three parts of study questionnaire. First part provided general guidelines for the study participants and contact information of researchers. The second part had 15 questions to get background information of participants. The third part comprised of 15 questions and assessed the knowledge of participants of survey regarding clinical case management of IMNCI. Second part required 5 to 7 minutes to complete. Each question in third part required 30 to 90 seconds to complete. Thus on an average estimated time to fill in the survey questionnaire was about half an hour. Part three of the questionnaire had total 15 marks for performance evaluation. Each question carried one mark. According to performance, every participant was given a final score which was between zero and fifteen.
4.3.2. Survey
As the questionnaire was based on clinical case management of IMNCI guidelines, pre-tested and pre-used in province Punjab of Pakistan so no pilot survey was done to assess the validity and reliability of survey questionnaire.
Principal researcher and co – researcher conducted this survey in their respective sectors during August 2011 to February 2012. In this survey, information was obtained by using pen and paper version of self-administered anonymous questionnaire.
During the study period, both researchers visited the survey PHCCs personally to collect data.
After presenting written permission of sector director to PHCC director to conduct the survey, questionnaires were distributed to the target population in each health facility. Every eligible participant was given a brief oral description about the study and survey questionnaire before the start of survey. From some centers the questionnaires were collected back by researchers on the same day, from others on the other day and from still others after few days of distribution through PHCC drivers.
Almost two reminders were given to all doctors and nurses who participated in the survey. Non- respondents were excluded from the study irrespective of their reason. Filled returned questionnaires served as consent to participate in the survey. Furthermore, all respondents were assured that they will be no leakage of any information and the data will be used only for the study purpose.
4.4 Research team
Principal researcher Dr. Muhammad Safdar was working in Sabya sector in Jizan region and co- researcher Dr. Rizwan Ahmad Khan was working in Tathleeth sector in Bisha region. Data collection for this survey was done in collaboration and both researchers collected data from their respective sectors.
4.5 Data management
On completion of survey, principal researcher created an EXCEL data base file and did double data entry. Comparison of two data was carried out and discrepancies were identified which were then corrected after consulting the original questionnaire data.
4.6 Ethical Issues of the study
Written permission to use the questionnaire for this survey and to make few modifications was obtained from co-researcher.
Written permission to conduct the survey was obtained from the directors (Mudeers) of both survey sectors.
Completing and returning of questionnaire was taken as consent of participants. The participants were given the right to withdraw the consent and discontinue the participation at any time during the survey.
All study participants were assured that the obtained information will be kept secret and used only for study purpose.
4.7 Funding for the Study
Necessary funding required for the survey was arranged by of the principal researcher out of his own pocket. All expenditures such as photocopies, travelling to PHCCs etc were paid by the principal researcher himself. Participation of co-researcher in this questionnaire survey was absolutely voluntary.
4.8 Analytical approach 4.8.1 Outcome measures
Each question in the questionnaire had one mark. Maximum score of questionnaire survey was 15. After the completion of survey, answers to the questionnaire of the survey were used to award a final score to each study participant. Final score of each study participant ranged from 0- 15. Questions in the survey questionnaire had been further sub-divided into parts for the purpose of awarding an accurate score to each participant.
4.8.2. Variables in analysis
Knowledge of clinical case management of IMNCI among health care workers was the main outcome variable. Other variables in the analysis were age, gender, designation, level of qualification, year of graduation, sector, nationality, IMNCI training status, country of graduation, months worked in Children ward and service duration in KSA. For the purpose of analysis, the study participants were broadly divided into two categories such as Sabya sector health workers and Tathleeth sector health professionals.
4.8.3. Statistical analysis
Analysis was done using Statistical Package for Social Sciences (SPSS) IBM Version 20.Mostly descriptive statistics was used for demographic, national, professional and educational characteristics. Univariate ANOVA was used to see the relationship among dependent and independent variables. One way ANOVA is used for comparison among variables having more than two categories. Each variable is described separately. A p-value of ≤ 0.05 was taken as statistically significant in all cases. Turkey’s Post Hoc test was used for pair-wise comparison among groups
5. RESULTS
5.1 Background of study participants in two sectors
Out of 229 eligible healthcare professionals, who were approached in both sectors, only 99 responded and returned the questionnaire. Total response rate was 43%. The response rate among nurses in Sabya sector was lower (14%) than in Tathleeth (68%) (Table 2)
Table2: Target population approached and responded in both sectors
Characteristics SABYA TATHLEETH
Total Responded Percentage Total Responded Percentage
Doctors 50 36 72% 45 24 53.3%
Nurses 96 13 13.5% 38 26 68.4%
Total 146 49 33.5% 83 50 60.2%
More females participated in the survey than males. Majority of participants were between 31 to 50 years old and mean age of participants is 38.5 years. In both sectors, participants were from different countries and mostly graduated from their native countries. Indian and Sudanese participants were predominant in the study (Table 3).
Table 3: Demographic and National characteristics of participants by study region
Characteristics
Sector
Total
Sabya Tathleeth
N % N % N %
Gender Male 26 53% 19 38% 45 45%
Female 23 47% 31 62% 54 55%
Age range
21 to 30 15 31% 11 22% 26 26%
31 to 40 12 24% 23 46% 35 35%
41 to 50 14 29% 13 26% 27 27%
51 to 60 8 16% 3 6% 11 11%
Nationality
Bangladesh 1 2% 3 6% 4 4%
Egypt 10 20% 3 6% 13 13%
Phillipine 3 6% 3 6% 6 6%
India 10 20% 20 40% 30 30%
Pakistan 6 12% 11 22% 17 17%
KSA 4 8% 0 0% 4 4%
Sudan 15 31% 8 16% 23 23%
Other 0 0% 2 4% 2 2%
Country of graduation
Bangladesh 1 2% 3 6% 4 4%
Egypt 10 20% 3 6% 13 13%
Phillipine 3 6% 3 6% 6 6%
India 10 20% 20 40% 30 30%
Pakistan 6 12% 11 22% 17 17%
KSA 4 8% 0 0% 4 4%
Sudan 15 31% 6 12% 21 21%
Other 0 0% 4 8% 4 4%
Majority of participant graduated after the year 1990.There was preponderance of doctors among participants. The service duration of about 40% of participants was between 3-10 years in KSA.
Only 4% participants had the post graduate qualification. About 70% participants did not get any IMNCI training during their studies. Only 6% of participants got on job IMNCI training. About 41% participants did not work in children ward (Table 4).
Table 4: Professional, training and educational characteristics of participants by region
Characteristics
Sector Total
Sabya Tathleeth
N % N % N %
Designation Doctor 36 72% 24 53.5% 60 60.6%
Nurse 13 13.5% 26 68.4% 39 39.3%
Qualification Graduate 49 100.0% 46 92.0% 95 96.0%
Postgraduate 0 0.0% 4 8.0% 4 4,0%
Service duration in KSA less than 3 years 21 43.0% 11 22.0% 32 32.0%
3 to 10 years 8 16.0% 32 64.0% 40 40.0%
more than 10 years
20 41.0% 7 14.0% 27 27.0%
Graduation
up to 1980 3 6.0% 0 0.0% 3 3.0%
1981 to 1990 15 31.0% 6 12.0% 21 21.0%
1991 to 2000 10 20.0% 23 46.0% 33 33.0%
2001 to 2010 21 43.0% 21 42.0% 42 42.0%
Months worked in Peads
not worked 15 31.0% 26 52.0% 41 41.0%
less than 6 months
20 41.0% 6 12.0% 26 26.0%
6 to 12 months 9 18.0% 12 24.0% 21 21.0%
more than 12 months
5 10.0% 6 12.0% 11 11.0%
IMNCI training during
studies Yes 16 33.0% 14 28.0% 30 30.0%
On-job IMNCI training Yes 0 0.0% 6 12.0% 6 6.0%
Other courses on child
health Yes 8 16.0% 32 64.0% 40 40.0%
In both sectors mean scores equal 7.03, the maximum score obtained by a participant is 13.2 out of 15(in Sabya)and minimum is 2.1 (in Tathleeth) see Table 5.
Table 5: Survey test scores by study sector
Sector Sabya
N=49
Tathleeth N=50
Total N=99
Mean Min Max SD Mean Min Max SD Mean Min Max SD
Obtained Score
7,0 2,4 13,2 2,6 7,0 2,1 12,6 2,2 7,0 2,1 13,2 2,4
5.2. Comparison of mean score between study groups
Overall, mean knowledge score about clinical case management of IMNCI among the study respondents were 7.03 (2.4). Mean knowledge score obtained by health care personnel in Sabya was 7.04 and Tathleeth was 7.02. Those who were trained for IMNCI during studies scored one much higher (9.09) than the untrained (6.13). Those who got on job training of IMNCI also scored one reasonably higher (9.75) compared to untrained (6.85) but the participants having on job IMNCI training are quite less (06) in numbers . In both sectors Sudanese and those graduated from Sudan were the top scorer (8.19). In both sectors nurses scored little less (6.49) than doctors (7.38). Males have mild high mean obtained score (7.23) than females (6.86). These who have experience of working in children ward for more than 12 months scored higher (7.11) than those having less experience. Those who have not attended other courses on child health scored little less (6.90) as compared to those who have attended (7.21) such courses.
Table 6: Comparison of mean obtained score between study groups
Characteristics N Means SD
Total 99 7.031 2.39
Sector Sabya Tathleeth
49 50
7.04 7.02
2.57 2.23 Gender
Male 45 7.23 2.56
Female 54 6,86 2.25 Designation
Doctors Nurses
60 39
7.38 6.49
2.63 1.87 IMNCI training
during studies Yes
No
30 69
9.09 6.13
2.15 1.89 On job IMNCI
training Yes
No
06 93
9.75 6.85
2.14 2.31 Other Courses on
child health Yes
No
40 59
7.21 6.90
2.37 2.42 Months worked in
Pediatrics Not worked Less than 6 months
6 to 12 months More than 12 months
41 26 21
6.26 7.56 7.11
1.73 2.92 2.09
11 8.46 2.39 Country of
graduation Bangladesh
Egypt Philippine
India Pakistan
KSA Sudan
04 13 6 30 17 04 21
6.00 6.03 7.30 6.54 7.48 4.34 8.19
1.15 1.78 1,25 2.19 1.48 2.80 3.17
5.3Relationship between variables – Univariate ANOVA
Table 7 shows basic information of variables such as levels or categories and their numbers.
There are 6 variables of interest with their level numbers.
Table 7. Basic information about levels of variables and number of participants.
Between-Subjects Factors
Value Label N
Gender 1 Male 45
2 Female 54
Designation 1 Doctor 60
2 Nurse 39
Country of graduation 1 Bangladesh 4
2 Egypt 13
3 Philippine 6
4 India 30
5 Pakistan 17
