Module summary

• Participants– 17 Barangay Health Workers (2 absentees)– 1 Midwife (Tita Letty Tejada)– 4 Interns – 1 Resident

• Venue: Escribano Barangay Hall and Health Center

• Time: 1400H-1630H (2 ½ hours)

Participants Demographic Data

College or Voca-tional

High School Elementary0123456789

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Chart 1. Frequency Distribution of Partic-ipants accdg to Educational Attainment

20-30 31-40 41-50 51-60 > 60012345678

Chart 2. Frequency Distribution of Partic-ipants accdg to Age

0-5 6-10 11-15 16-20 21-25 > 25 Unspecified0

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Chart 3. Frequency Distribution of Participantsaccdg to Length of Service

Majority of BHWs are aged 31-40, with 6-10 years of service and has finished high school

Chart 7. Frequency Distribution of Pre- and Post-Test Scores

1 2 3 4 5 6 7 8 9 100

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Pre-TestPost-Test

Pre-Test Post-Test % ChangeMean 6.2 7.8 25.7%Median 6 7.5Mode 7 6

Mean and median scores increased from pre- to post-test. Mean score increased by approximately 25.7%.

Problem 1

• With the initial findings, we were curious if there was a trend among the different demographic data of our BHWs.

• This involved analyzing the pre and post test scores of our BHWs against their age group, educational attainment and length of service

• Among BHWs in Escribano, is there a trend of pre and post test scores among the different demographic data (age, length of service and educational attainment)?

Chart 4. Mean Pre- and Post-Test Comparisons accdg to Educational Attainment

There are no apparently big differences in the pre- and post-test scores among college, high school and elementary graduates. However, high school graduates have lower % change compared to either college or elementary graduates.

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Mean Pre-Test Score

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Elementary High School College orVocational

Chart 5. Mean Pre- and Post-Test Comparisons accdg to Age

In general, participants in the 31-50 age groups showed greater improvements compared to their more elderly counterparts.

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20-30 31-40 41-50 51-60

Only 1 participant belonged to the 20-30 age group

Chart 6. Mean Pre- and Post-Test Comparisons accdg to Length of Service

The trend is towards decreasing rates of improvement between pre- and post-test scores with increasing length of service, with the possible exception of those with > 25 years of experience as a BHW.

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Mean Pre-Test Score

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The BNS failed to specify her length of service

0-5 6-10 16-20 > 25 Unspec

Insights

• After analysis of the data, there were some interesting trends:- There is a negative correlation between pre and post test score against

increasing age groups- Similarly, there is also a negative correlation between increasing length

of service and scores- Among the participants, elementary graduates were the most receptive

as shown in their scores.

• It is easy to be overwhelmed by the here and the now and forget much about the past:– BHWs were only intent on filling up the IMCI form on ear infections.– When reviewed about the previous modules, BHWs seem to have

forgotten about 50% of them.

UP-CHDP Problem TreeHigh Morbidity in Children (0-12) due to infectious disease (ie,

pneumonia, diarrhea, URTI, dental caries)

Malnutrition Poor Environmental SanitationLack in Personal Hygiene

Lack of SanitaryToilets Limited water resource (access & quality)

Poor Waste mgtPoor dental health

Lack of food access

Improper diet & food intake (?)

Underdeveloped H20 sys

Lack of maintenance of H20 System

Lack of H20 source in some areas

Lack of knowledge

Inaccessibility to healthcare

Poor (unhealthy) practices

Poor attitude

Lack of govt funds

Lack of family income

Lack of livelihood opportunities

Inadequate accessibility to healthcare

Lack of medicines, inefficient referral system

Poor access to the health care system

Objective

At the end of the 5-week rotation, at least 80% of Barangay Health Workers in Cluster 4 should have been able – both in theory and in practice – to classify and manage children aged 2 months to 5 years of age according to the IMCI guidelines until the Ear Module

-to address our objectives we plan to:1)Conduct the Ear Module for the Cluster 4 BHWs,2)To possibly conduct review sessions when

needed.

IMCI Chart Review

• Flow chart

Chart . Frequency Distribution Vital Signs Monitoring

Majority of BHWs were able to accurately monitor the vital signs of patients.

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Escribano Muzon

Chart . Frequency Distribution of Eliciting the Chief Complaint

96% of the BHWs were able to elicit the chief complaint. Majority of whom had the chief complaint of cough and colds

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Not Filled Up

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Vomiting4%

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OTHERS

Chart . Frequency Distribution of Reporting Details in the IMCI Chart

Most of the BHWs are able to assess the patient in their IMCI charts.

Danger Signs Cough Diarrhea Fever Ear Infection0%

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Chart . Frequency Distribution of Classifying in the IMCI Chart

Most of the time, the BHWs do not write any classification on the IMCI charts.

Danger Signs Cough Diarrhea Fever Ear Infection0%

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Correct and Complete Classification Correct But Incomplete ClassificationIncorrect Classification No Classification

Insights

• The IMCI chart is reflective of the BHWs problematic areas.-Most of the BHWs are able to monitor the vital signs but easily interchange the heart rate and the respiratory rate.

- It is easier to assess patients when given a simple checklist where the symptoms are elicited by direct questioning

-Classifying patients appear to be most difficult.

Problem 2

• Would review/ retraining sessions be warranted to improve the performance of BHWs in both assessing and classifying patients based on their IMCI charts?

• How would review/ retraining sessions affect the performance of BHWs in both assessing and classifying patients based on their IMCI charts?

Journal

Journal Appraisal

• Relevant• Validity• Reliable• Applicable

Methodology

IMCI Listings(1) the presence or absence of specific symptoms

(2) classifications (i.e. diagnoses); and (3) treatments.

IMCI Chart Review

Data gathering on consultations performed by 114 ACTIVE CHWs( March

1997 to May2002) VIA systematic sampling.

INCLUSION CRITERIA(1) Recorded in registers up to 5 years after

the CHW became active(2) Involved an ill child aged 0–59 months(3) Initial consultations(4) In the village(5) Recorded by the CHW and not by his/

her supervisor(6) Involved an ill child for whom the

documentation of assessment findings was sufficient to allow the determination of recommended treatments

(7) Involved an ill child for whom one or more treatments should have been prescribed (quality of treatment was only assessed among patients for whom a drug or referral was indicated).

Definition of Terms

• Adherence score- defined as the percentage of guideline-recommended treatments prescribed for each patient. This score was a continuous variable ranging from 0% to 100% and encompassed seven treatments: five oral drugs, one antibiotic eye ointment and referral to a health facility if indicated

Data Analysis

HYPOTHESIS:1) Adherence declined with

time2) Refresher training had

an immediate, positive impact on the mean adherence level after refresher training

3) Refresher training had a positive impact on trends in adherence

TECHNIQUEScatter plots and robust locally weighted smoothing techniques to visualize patterns in adherence.

PRELIMINARY ANALYSIS • Mean adherence scores for

consultations performed by CHWs (initial, 1st training, 2nd training)

• Mean adherence scores across categorical levels of covariates.

Data Analysis

Piecewise random effects linear regression models

• Knot= time at which a change occurs (e.g. time of refresher training)

• Intercept= mean adherence score at the beginning of a time period

• Slope= the rate of change in adherence scores over time

WHY?

The model allowed for the estimation of the change in the intercept at each knot and the change in the slope after the knot.

ResultsThere is a notable similarity between the decreasing score during the IMCI Ear module training and the initial analysis of data against covariates in the study.

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Chart 7. Mean Pre- and Post-Test Score Comparison accdg to Age

Mean Pre-Test Score

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ResultsTreatment adherence score is highest among high school graduates in the study (levels 9-11) as compared to our data with the highest scores belonging to the elementary level.

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Chart 6. Mean Pre- and Post-Test Score Comparison accdg to Educational Attainment

Mean Pre-Test Score

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Scatter Plots

AS: 78% AS: 85% AS: 85%

Interpretation

• W/O TRAINING: mean adherence level to continue at about 78% per patient per 3-month period.

• 1ST REFRESHER: INCREASE in mean adherence level was about 85%. Furthermore, adherence continued to rise during the post-first-refresher period, flattened, and then curved downwards (Figure 2).

• 2ND REFRESHER: the mean adherence level did not improve immediately after the second refresher training, and adherence scores declined rapidly after the second refresher training

Results

The adherence scores were higher in consultations in which the patient:

1) Did not have a severe classification, diarrhea, cough or a danger sign.

2) The patient had a moderate classification3) The consultation was recorded on the revised version of

the register4) The patient was treated by a CHW who was under 50

years of age5) As the number of supervisory visits recorded in the

register increased so did the adherence score

In Summary…

• The first refresher training was helpful in improving CHWs’ skills in treating severely ill patients is consistent with one of the intended purposes of refresher training: to improve CHWs’ skills in managing severely ill patients.