Ascerting the effectiveness of community integrated management of childhood and neonatal illness (C-IMNCI) through assessing mothers` knowledge and practice and exploring perceptions of the C-IMNCI trained lady health workers in District Quetta

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Background/ Rationale Millennium Development Goal 4 (MDG 4) calls for reduction in under-five mortality rate to two-thirds by 2015. As a signatory to MDGs, Pakistan is struggling to achieve MDG4. The under five mortality rate in Pakistan i.e. 94 deaths per 1000 live births, is one of the highest in the region. The Pakistan Demographic and Health Survey highlighted the fact that infant and child mortality has hardly changed in over a decade. There are strategies to combat the problem, one of which is Integrated Management of Childhood and Neonatal Illnesses (IMNCI), comprising of three components; i) improving case management skills of health providers, ii) health system strengthening and iii) improving family and community practices referred as "Community- IMNCI". Pakistan has a large pool of CHWs designated as Lady Health Workers (LHWs), deployed in every part of the country, who could be responsible for implementing C-IMNCI. C-IMNCI trainings were provided to the LHWs in selected districts within the country by Pakistan Initiative for mothers and newborns (PAIMAN). District Quetta was one of the focus districts of the PAIMAN, therefore C-IMNCI trainings were imparted to 208 LHWs there. The success of IMNCI in general has been proven through several studies and C-IMNCI as a component of IMNCI has also been studied in which it was observed that the strategy can help in improving the practices of the mothers related to child health. Although few studies have examined changes in child health related knowledge and practices of care givers as a result of community IMNCI interventions, however there is dearth of knowledge regarding the effectiveness of training LHWs in C-IMNCI and its impact on increasing mothers' knowledge and practices in the Pakistan context. This study was intended to examine the effectiveness of Civ IMNCI strategy in district Quetta, on improving the knowledge and practices related to child health of under five mothers. Methods The study objectives were explored in Quetta city of Baluchistan within, a time period of three months i.e. from July to September 2011.We conducted a cross sectional survey in Quetta city to assess the knowledge and practices of care givers related to child health, the study population were500 mothers of children less than 5 years, served by LHWs who had received the supplemental C-IMNCI training and those LHWs who had received routine training only. To explore the perceptions of the LHWs about the C-IMNCI strategy, four focus group discussions were carried with C-IMNCI trained LHWs. Results The survey results highlighted that there was no significant difference in the knowledge and practices of the mothers' related to C-IMNCI practices between the two groups. Specifically, there was no difference in growth and development promoting practices, i.e. optimal breast and complementary feeding practices and early childhood development practices; disease prevention practices, appropriate care at home when child is sick, care seeking practices outside home and routine immunization status between mothers who were served by the C-IMNCI trained LHWs versus those served by routinely trained LHWs. The single significant difference between the two groups was that mothers served by C-INMCI trained LHWs were more than twice as likely to seek care for childhood illness from the LHWs as compared to mothers served by routinely trained LHWs. The perceptions of the LHWs were found to be generally positive about the CIMNCI strategy. The hindering factors highlighted by the LHWs for successful implementation of the strategy in the community were lack of logistic support, irregular supervision and problems in referral. Conclusion Our study did not find the C-IMNCI training strategy to be effective, in making any difference in the knowledge and practices of mothers with respect to key practices of the C-IMNCI strategy, however, the strategy itself was perceived positively by the LHWs. For the effective implementation of the C-IMNCI strategy, the C-IMNCI framework proposes three programmatic elements and a multi-sectoral platform that focus on specific behaviors and practices of health workers and caregivers of young children; i)Partnerships between health facilities and the communities, increase utilization of health facilities and establishment of mechanisms for community feedback on and/or management of health facilities, ii)Increase quality of care from CHWs, promotion of preventive practices by CHWs and decrease harmful practices of community-based providers, iii) Increase adoption of family practices for health, nutrition and development, engaging communities in the selection of behaviors to be promoted and identification of actions to be taken. The trainings provided to the LHWs was only supporting element two of the strategy. We were not able to assess or explore the level of partnership development between the health facilities and the communities i.e. element one of the framework. The third element of the framework emphasizes on the health promoting messages through incorporating coordinated and strategic use of the mass media through national and regional channels of communication, linked closely with behavior change efforts at the district and community levels. We postulate that for effective implementation of the C-IMNCI strategy, the non-governmental organizations or the government programmes interested in implementing the C-IMNCI strategy, should view the strategy holistically in their planning phase, in order to achieve the desired impact on the knowledge and practices of the caregivers for reducing the under five morbidities and mortalities. The constraining factors highlighted by the LHWs, need to be addressed on priority basis by the health department, in particular by the National programme for Family Planning and Primary Health Care for the maximum utilization of this cadre of health work force.

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