|Year : 2014 | Volume
| Issue : 2 | Page : 70-76
Community-integrated management of childhood Illnesses (C-IMCI) and key household practices in Kano, Northwest Nigeria
Abubakar Mohammed Jibo1, Zubairu Iliyasu1, Isa Sadeeq Abubakar1, Lawan Muhammad Umar1, Aliyu Muktar Hassan2
1 Department of Community Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Associate Director for Research in the Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
|Date of Submission||18-Nov-2013|
|Date of Acceptance||02-Apr-2014|
|Date of Web Publication||16-Jul-2014|
Abubakar Mohammed Jibo
Department of Community Medicine, Aminu Kano Teaching Hospital, PMB 3452, Kano, Nigeria
Introduction: Integrated management of childhood illnesses (IMCI) is a holistic approach to reducing under-5 morbidity and mortality, and improving growth and development of children. This study compared key household and community practices in IMCI implementing and non-implementing communities in two local government areas (LGAs) of Kano State, Nigeria. Materials and Methods: A cross-sectional study was employed with multistage cluster sampling selection of caregivers of children 0-59 months of age and their index children (n = 400). The study was conducted from February 2009 through January 2010. Data analysis was performed using EpiInfo TM v6.0 and Minitab TM software. Results: The adoption of IMCI key household and community practices was generally better in IMCI-implementing communities than in non-IMCI communities. Exclusive breastfeeding (EBF) rate among children under 6 months was higher in IMCI communities than in non-IMCI communities (P = 0.05). Non-IMCI communities also had a greater proportion of low weight-for-age children (42.5%) than IMCI communities. Mothers from IMCI communities (30.5%) were more likely to have antenatal care (ANC) during the first trimester than those from non-IMCI communities (P < 0.05). There was no difference between the study communities with regard to use of insecticide-treated nets (ITN) during pregnancy (P = 0.09), and having skilled attendance during last childbirth (P = 0.23). Conclusion: Mothers in communities implementing IMCI are more likely to adopt EBF and to attend ANC services than their counterparts in communities not implementing IMCI. Expanding IMCI activities to other LGAs in northwest Nigeria will have a positive impact on reducing morbidity from common childhood diseases.
Keywords: Household practices, integrated management of childhood illness, Nigeria, under-5 morbidity
|How to cite this article:|
Jibo AM, Iliyasu Z, Abubakar IS, Umar LM, Hassan AM. Community-integrated management of childhood Illnesses (C-IMCI) and key household practices in Kano, Northwest Nigeria. Sub-Saharan Afr J Med 2014;1:70-6
|How to cite this URL:|
Jibo AM, Iliyasu Z, Abubakar IS, Umar LM, Hassan AM. Community-integrated management of childhood Illnesses (C-IMCI) and key household practices in Kano, Northwest Nigeria. Sub-Saharan Afr J Med [serial online] 2014 [cited 2019 Nov 12];1:70-6. Available from: http://www.ssajm.org/text.asp?2014/1/2/70/136810
| Introduction|| |
Every year about 10.2 million children die before they reach their fifth birthday, most of them during the first year of life.  Majority of these deaths are due to diarrhea, pneumonia, measles, malaria, malnutrition, or often a combination of these conditions.  Nearly 90% of these deaths occur in just 42 countries,  mostly low-income countries or poor communities in middle-income countries.  Six countries, namely India, Nigeria, China, Pakistan, Democratic Republic of Congo, and Ethiopia  are said to account for half of these deaths. Although the highest absolute number of deaths occur in South Asia, the highest death rates are found in sub-Saharan Africa where mortality is actually increasing, with over 60% of these deaths being preventable. 
Cost-effective interventions are available for all major causes of child mortality, but coverage with these interventions are appallingly low in the 42 countries that contribute 90% of child deaths globally. The global death toll in young children has fallen dramatically in the past half-century. However, since the mid-1990s, the pace of decline has been slowing down, and in some countries, the downward curve has leveled or is even starting to rise again. Africa has recorded the most sluggish decline in child mortality among the six World Health Organization (WHO) regions, 42% compared with 60-72% from other regions.  These gaps exist despite the availability of effective interventions  and initiatives, such as growth monitoring, oral rehydration, breast feeding, immunization (GOBI)  and global commitment to health for all by the year 2000.  While these gaps might have been greater in the absence of these strategies, it is clear that these initiatives have come nowhere close to eliminating them.  The response to these was the development of a set of simple, affordable, and effective interventions for the integrated management of the major childhood illness (IMCI).  IMCI was developed by WHO, United Nations Children's Fund (UNICEF), and other partners in 1992.  It combines effective interventions for preventing death, health promotion, and growth development. The IMCI strategy has three components: improving the skills of the health workers, improving the health system support for IMCI, and improving family and community practices.
Many countries in Africa, including Nigeria adopted the IMCI strategy in an effort to curtail the high levels of child mortality existing within their population. The strategy was introduced in different phases by different countries under the technical guidance of WHO/UNICEF. Nigeria, a country with the 14 th lowest child survival rates in the world  since her independence from Britain in 1960, has maintained a very low average annual rate (0.3%) of under-5 mortality reduction.  It has only succeeded in reducing childhood mortality rate by 5.3% in 45 years, from 207 deaths per 1000 live births in 1960 to 194 deaths per 1000 live births in 2005, a value that is approximately three times less than the global target of reduction for the year 2000.  As in most countries, mortality rates in infancy and early childhood in Nigeria are higher in rural areas than in urban areas. The indicators for child survival are worst for the poorest in the country. A child born in Nigeria is about 30 times more at risk of death, before reaching the age of five, than a baby born in industrialized countries. Since independence in 1960, Nigeria has maintained a very low average annual rate (0.3%) of under-5 mortality reduction.  Nigeria has only succeeded in reducing childhood mortality rate by 5.3% in 45 years, from 207 deaths per 1000 live births in 1960 to 194 deaths per 1000 live births in 2005, a value that is approximately three times less than the global target of reduction for the year 2000.  Whereas child survival rates in the richest families are increasing, the poorest families have continued to witness a progressive worsening in their infant and under-5 mortality rates.
A number of interventions exist in the communities and at family levels that can significantly reduce child morbidity and mortality. Most of the families in IMCI communities receive training on key household practices influencing child health from community resource persons (CORPS). These CORPS are usually members of the community who have received training on community IMCI.
In some African countries, levels of IMCI implementation as well as its impact have been evaluated and results have shown promising results. The first two components of IMCI target significant improvements in the skills of health care workers and health system strengthening, while the third aims at improving key family and community practices influencing child health. Except for a national review conducted in 2005 by Federal Ministry of Health in Nigeria in collaboration with WHO, there has been no scientific evaluation of the effect of IMCI implementation on child health done elsewhere in Nigeria. This study therefore seeks to determine the effect of IMCI implementation on key family and community practices that influence child health in IMCI-implementation communities in northern Nigeria.
| Materials and Methods|| |
Two LGAs in Kano State, namely, Kano Municipal and Tarauni LGAs, both metropolitan LGAs of Kano State were selected for the study. Kano Municipal is an IMCI-implementing LGA; so, it was purposively selected for the survey, while Tarauni a non-IMCI local government was selected using simple random sampling technique from the list of seven other metropolitan LGAs. These two LGAs are however similar in demographic characteristics.
Cross sectional descriptive survey.
The study population includes mothers and caregivers of children aged 0-5 years in IMCI and non-IMCI implementing communities. Also included are children aged 0-5 years in these study communities.
Sample Size Determination
The sample size formula for determining sample size for comparative study was used. Thus, the formula:
Therefore, the minimum sample size used for the survey was 200 caregivers of children aged 0-5 years each from IMCI and non-IMCI communities.
A multistage cluster sampling technique was employed to recruit 200 mothers or caregivers of children from IMCI-implementing and 200 from non-IMCI-implementing communities, respectively.
Two IMCI-implementing wards were purposively sampled from the list of 13 wards that made up Kano Municipal (IMCI-implementing LGA). In the non-IMCI implementing LGA, two wards were selected using simple random sampling technique from the list of ten wards that made up Tarauni LGA council. The list of clusters that made up the communities in the wards was determined from each of the selected wards.
In the two study LGAs, two clusters were selected using simple random sampling from the list of clusters in each ward and respondents were determined.
All houses from the selected clusters were studied in this stage. The selection of eligible caregiver/child (0-59 months) from the households, where there was more than one eligible caregiver/child in a household, selection was done by balloting. The same procedure was applied in the comparison LGA until the sample size was obtained.
Ten research assistants were trained for this survey. They had 3 days training on data-collection techniques and participated in the pretest of the questionnaires on the third day of the training. Tools used for the health facility component were adapted from IMCI/health facility survey (HFS) tools, IMCI/multi-country evaluation (MCE), and federal ministry of health (FMOH) IMCI baseline survey tools. The questionnaires were interviewer administered. The questionnaire consisted of structured and coded questions. The questionnaires collected key information on key household and community.
Data collected from all the questionnaires were entered into Excel software. Data was then analyzed using Minitab and Epi info statistical softwares. Summary indices were employed to describe qualitative variables. Chi-square test was employed to test for statistical associations. Significant associations were observed for any P value less than 0.05
Ethical permission was obtained from the ethics committee of Aminu Kano Teaching Hospital, Kano. Permission to conduct the study was also obtained from both the Kano Municipal and Tarauni Local councils. Similarly households and respondents have given their respective verbal consents before being enrolled for the survey.
| Results|| |
Four hundred questionnaires were administered in the two communities. The response rate was 100% for this survey. The mean age of caregivers in IMCI communities was 31 years with standard deviation of 9.1 and 29 years with standard deviation of 8.9 years in non-IMCI community.
Mothers constituted 77.5% of the respondents in IMCI community and 84.5% in non-IMCI communities, while fathers constituted 21.5% of the respondents in IMCI-implementing communities and 14.5% in non-IMCI communities. Grandparents constituted 1% of the respondents in either communities with house help constituting 0.5% of the respondents in IMCI communities. All but 30 (7.5%) of the caregivers had some form of education or the other in IMCI-implementing and -nonimplementing communities.
The mean age for index children in IMCI communities was 22 months with standard deviation of 12.3 while the mean age for children in non-IMCI communities was 16 months with standard deviation of 13.9. Of the 400 index children enrolled for the study, 184 (46.0%) were males while 216 (54.0%) were females as shown in [Table 1]. The mean weight of children studied in IMCI communities was 10.9 kg with standard deviation of 4.5 compared to the mean of 8.46 kg with standard deviation of 3.8 in non-IMCI communities
A greater proportion of children under 6 months from the IMCI-implementing communities (23.2%) were exclusively breastfed compared to those from the non-IMCI community (6.1%, P = 0.05). The prelacteal feeding rate was higher in the non-IMCI community (22%) than in IMCI-implementing communities (8.5%, P < 0.05). There was a significant difference (P < 0.05) between the two study communities with regard to use of pre lacteal feeds, as shown in [Table 2]. Commonly given prelacteal feeds were Zam zam 22 (11.0%) in non-IMCI community and 12 (6.0%) in IMCI community, honey 6 (3.0%) in IMCI communities and 12(6.0%) in non-IMCI communities, and plain water 1 (0.5%) in IMCI and 6 (3.0%) in the non-IMCI communities. The proportion of mothers that started the newborn on breast milk within an hour of birth was 37 (18.5%) in IMCI communities and twice the number of children started in the comparative communities 14 (7.0%, P < 0.05). The difference is statiscally significant as shown in [Table 2].
For children aged 6-12 months, the mean age of introduction of complementary feeds was 4 months in non-IMCI communities compared to 6 months among children in IMCI communities. Pap was the most popular complementary feed used, and could be a thick or thin pap. Many caregivers admitted to enriching the child's pap with additives, such as sugar (60.8% in IMCI and 45.1% in non-IMCI); milk (16.2% in IMCI and 15.9% in non-IMCI); and groundnut, soya beans, or palm oil (12.3% in IMCI and 8.5% in non-IMCI). One-third of the caregivers in non-IMCI communities (30.5%) do not add anything to the child's pap compared to 10% of the caregivers in IMCI-implementing community who do not add anything to the pap.
Less than a quarter of the index children 46/200 (23%) from the non-IMCI communities had immunization/child health cards compared to close to half 91/200 (45.5%) of the children with immunization records or child health card in IMCI communities. Approximately 50.3% and 27.1% of children whose growth-monitoring cards were seen in the non-IMCI and IMCI communities had any evidence of growth-monitoring activity, as shown by weight records documented in their cards. No difference in vitamin A supplementation rate in children was observed between study communities (62.6% in IMCI and 66.7% in the non-IMCI communities, P = 0.46).
Caregivers from two study communities differed with regard to what they do at home to prevent disease in a child. Children that slept under ITN the night before the survey were observed to be higher in the IMCI communities, 23 (11.5%) when compared to 14 (7.0%) in non-IMCI communities, although the difference was not significant (P > 0.05). More caregivers practice hand washing after using toilet, cleaning a child, or before and after feeding the child in IMCI communities (88.5%) compared to caregivers in non-IMCI communities (75.5%, P < 0.05). Assessing the knowledge of the two communities on methods of preventing HIV infection, this study showed a higher knowledge scores in IMCI communities (63%) relative to 48.5% scores observed in non-IMCI Communities.
Prevalence of Common Childhood Health Problems
More children from the non-IMCI communities had diarrhea (44%) and cough (52.5%) 2 weeks preceding this study than children in the IMCI communities (17.5% for diarrhea and 38% for cough, P < 0.05 and P = 0.05, respectively). However, no significant difference was observed (P > 0.05) between the two communities on the prevalence of fever 2 weeks preceding this study.
Children that were fully immunized were observed to be 12 (9.2%) in IMCI communities and 9 (8.8%) in the comparative communities. There was no statistical difference seen between the two IMCI and non-IMCI communities in terms of the immunization coverage (P > 0.05). The proportion of children immunized against diphtheria, pertussis, and tetanus (DPT3 coverage) was 11 (8.4%) in IMCI communities compared to 9 (7.6%) in non-IMCI communities. This finding was not statistically significant (P = 0.52). However, Bacillus Calmette-Guιrin (BCG) vaccine coverage was found to be significantly different (P < 0.05) between the communities.
Community Source of Information on Key Household Practice
Majority of caregivers admit to getting their source of information on household practices from the CORPS in IMCI communities 128 (64.0%), whereas the main source of information in non-IMCI communities are radio and television 87 (43.5%) and health workers 31 (15.5%). CORPS/community health worker (CHW) and radio/television were the two sources of information on household practices in IMCI (64%) and non-IMCI (43%) communities.
| Discussion|| |
0Caregivers' Knowledge on Community and Household Practices
This study has demonstrated the benefits of interventions like IMCI in our communities. Fewer children from the IMCI communities than their counterparts from non-IMCI communities were observed to have experienced some common childhood disorders. This was similar to what was reported by Ebuehi from Ife, Southern Nigeria  that after implementation of IMCI, the prevalence of diarrhea and cough were reduced from baseline values of 13% and 29.9% to 9.5% and 18.6%, respectively, following IMCI introduction. This could have been contributed by the improved household practices like proper hand washing and improved personal hygiene practices in IMCI communities. A study in Bangladesh  found out that implementation of IMCI led to improved health-worker skills, health-system support, as well as family and community practices, translating into increased care-seeking for illnesses. Study done in estimating a 2-week prevalence for common childhood illnesses targeted by the national IMCI initiative in Lagos Island, Adegboyega,  it reported that 450 out of 490 mothers were identified. Of these, 426 (86.1%) children belonging to 390 mothers/caregivers had symptoms suggestive of malaria, acute respiratory infections, diarrhea, and measles. This showed a high prevalence compared to what was seen in communities where IMCI has been implemented. 
Effect of IMCI on Some Indicators of Health Status
The proportion of children observed to be having low weight for their age was lower in IMCI-implementing communities than in comparison communities [Table 3]. This may have demonstrated the likely benefits of adequate nutrition knowledge and practices among the caregivers in IMCI communities. This study reported more children having low weight for their age in 12-23 age group in non-IMCI communities in contrast to Ebuehi  in Ile Ife who reported low weight for children in all age-groups in comparison LGA. Another study in rural Bangladesh showed that in IMCI areas, prevalence of stunting in children aged 24-59 months decreased more rapidly than in comparison areas after IMCI introduction. Thus, IMCI is likely to be associated with positive changes in all input, output, and outcome indicators, including increased prevalence of EBF and decreased stunting. 
Better EBF practices were observed in IMCI communities (P < 0.05) than in the non-IMCI ones; this is close to the findings of Haiderand Nankunda in Bangladesh  who observed that using community-based peer counselors contributed to increased EBF rates. Effects observed on infants aged 0-5 months who were not exclusively breastfed as reported by Vaahtera and Kulmala in Malawi were a seven-and fivefold increased risk of dying from diarrhea and pneumonia, respectively, in comparison to those exclusively breastfed. 
This study highlights the introduction of complementary feeds at earlier period of 4 months in more than half of the respondents from the non-IMCI communities as opposed to the recommended 6 months. These findings agree with those of Vaahtera et al., who observed that in rural Malawi, feeds were introduced at median ages of 2.5 months (much earlier than recommended). The introduction of complementary feeding earlier than recommended has negative effects on child survival, growth and development as it does not allow mothers to practice proper EBF, and predisposes the child to increased risk of infection and malnutrition, among others. Pap was the most common complementary feed, but more caregivers provide thick pap mostly enriched with milk in IMCI communities than their counterparts in non-IMCI communities. The practice of giving thin pap as a complementary feed provides poor quality food for a child at a period of early physical growth and intellectual development. This was similarly reported by Lartey et al., in Ghana, where they observed that infants fed with "fortified pap" had improved growth compared to those that did not receive a fortified pap. This may be the reason why a relatively higher percentage of underweight was observed among children 12-23 age-group in the non-IMCI communities.
The proportion of children that were fully immunized as recorded in their cards was also higher in IMCI communities, although there was no significant difference observed (P > 0.05) in the immunization coverage between IMCI implementing and nonimplementing communities. This observation differs from results reported by Victora et al., who showed that vaccine coverage had improved in all districts (IMCI and non-IMCI) but changes in immunization were more positive in IMCI districts.
More caregivers were observed to have had ANC during their last pregnancies in IMCI than non-IMCI communities [Table 4], This finding is not statistically significant (P>0.05). These findings are higher than the national average for the country. Perhaps because the study was done in an urban area, more pregnant mothers were observed to have had ANC visit and hence the higher responses observed. According to national demographic and health survey (NDHS),  58% of women who gave birth in the 5 years preceding the survey received ANC at least once. Furthermore, mothers who were observed to have had at least two doses of tetanus toxoid in their lifetime are higher in the study communities compared to the national average reported by the NDHS.  The NDHS reported that 40% of women received two or more doses of tetanus toxoid during their last pregnancies. Similar explanation can be offered as above, however, the possibility of having a spillover effect of IMCI to the neighboring communities cannot be completely ruled out. The result shows more caregivers attended ANC in IMCI communities than in comparison communities. This could be an explanation for positive effects of the intervention. The use of ITN during pregnancy for the prevention of malaria was generally poor in both communities with IMCI communities [Table 4], having 8.5% of mothers using ITN this finding is not statistically significant [P = 0.09]. This is higher than the value reported by 2008 NDHS  which had only 4.8% of pregnant mothers aged 15-49 years slept under ITN in Nigeria the night before the survey. Probably the campaigns against malaria in pregnancy and information from community resource persons in IMCI communities have begun to yield positive results. Women from the study communities who had their deliveries under skilled attendance were 13.5% in IMCI compared to non-IMCI community 12 (9.3%). These findings were lower than the national average, where 39% of deliveries were attended by skilled workers as reported by 2008 NDHS. Most deliveries in this part of the country take place at home, so it is not unlikely when even IMCI communities' record lower-skilled attendance at delivery.
In summary, the study had found out improved child health practices in communities where IMCI has been implemented over the last few years. Children in IMCI communities were more likely to be fully immunized than their counterparts from non-IMCI communities. Improved utilization of available health care services and improved nutritional practices were also observed in IMCI communities. The findings of this study might have revealed the positive effect of IMCI but a lot of questions remain unanswered on other probable confounding factors, such as improved socioeconomic status that could equally produce similar findings. This is an area where further research is required.
| References|| |
|1.||World Health Organization. Division of Diarrhea and Acute respiratory diseases control: Integrated management of the sick child. Bull World Health Organ 1995;73:735-40. |
|2.||Black RE, Morris SS, Bryce J. Where and why are ten million children dying every year? Lancet 2003;361:2226-34. |
|3.||UNICEF. State of the World Children 2002: Leadership; the rate of progress. Available from: http://www.unicef.org/sowc02/1980's.htm [Last accessed on 2006 Nov 29]. |
|4.||Horton R. UNICEF leadership 2005 to 2015; a call for a strategic change. Lancet 2004;364:2071-4. |
|5.||UNICEF: State of the World Children 2005. Available from: http://www.UNICEF.org/SOWC05/files/SOWC_05_Eng.Pdf [Last accessed on 2009 Dec 5]. |
|6.||Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio child survival study group. How many child deaths can we prevent this year? Lancet 2003;362:65-71. |
|7.||Annan KA. We the children: Meeting the promises of World Summit for children, NewYork, UNICEF/UN2001. Available from: http://www.unicef.org/specialsession/about/sgreport.pdf/sgreport-adopted-eng-pdf [Last accessed on 2005 Jul 20]. |
|8.||WHO, IMCI planning guide: Gaining experience with IMCI strategy in a country. Geneva: World Health Organization document. WHO/CHS/CAH/99.1 |
|9.||World Health Organization. Report on the International Conference on Primary Health Care. Alma Ata, September 6-12, Geneva: WHO; 1978. |
|10.||World Health Organization: Integrated management of childhood illness: A WHO/UNICEF initiative. Bull World Health Organ 1997;75:1-5. |
|11.||Lambrechts T, Bryce J, Orinda V. Integrated management of children illness, a summary of first experiences. Bull World Health Organ 1999;777:582-94. |
|12.||UNICEF: State of the World Children 2008. Available from: http://www.unicef.org/sowc08/docs/SOAC_2008_EN_A4.pdf [Last accessed on 2009 Dec 5]. |
|13.||Nigerian Academy of Science: Reducing Child Mortality in Nigeria The Way Forward. Lagos: West African Book Publishers Limited; 2009. p. 1-12. |
|14.||Singha P. Introductory text on Biostatistics. 3 rd ed. Kaduna: Dabco Investment Limited 1996. |
|15.||Ebuehi OM. Health care for under-fives in Ile-Ife, South-West Nigeria: Effect of the Integrated Management of childhood Ilnesses (IMCI) strategy on growth and development of under-fives. Afr J Prim Health Care Fam Med 2009;1:1-8. |
|16.||Arifeen SE, Hoque DM, Akter T, Rahman M, Hoque ME, et al. Effect of the integrated management of childhood illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: A cluster randomised trial. Lancet 2009;374: 393-403. |
|17.||Adegboyega AA, Onayade AA, Salawu O. Care-seeking behaviour of caregivers for common childhood illnesses in Lagos Island Local Government Area, Nigeria. Niger J Med 2005;14:65-71. |
|18.||Haider R, Ashworth A, Kabir I, Huttly SR. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: A randomized controlled trial. Lancet 2000;356:1643-7. |
|19.||Vaahtera M, Kulmala T, Hietanen A, Ndekha M, Cullinan T, Salin ML, et al. Breastfeeding and complementary feeding practices in rural Malawi. Acta Paediatr 2001;90:328-32. |
|20.||Lartey A, Manu A, Brown KH, Peerson JM, Dewey KG. A randomized, community-based trial of the effects of improved, centrally processed complementary foods on growth and micronutrient status of Ghanaian infants from 6 to 12 months of age. Am J Clin Nutr 1999;70:391-404. |
|21.||Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP, et al. Applying equity lens to child health and mortality: More of the same is not enough. Lancet 2003;362:233-41. |
|22.||NDHS. Nigeria demographic and health survey Preliminary reports and Key findings; 2003. |
|23.||NDHS. Nigeria demographic and health survey Key findings; 2008. |
[Table 1], [Table 2], [Table 3], [Table 4]