 |
|
Original Articles Indian Pediatrics 2003; 40:713-718 |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Sutapa Bandyopadhyay, Rajesh Kumar, Sunit Singhi, Arun K. Aggarwal
Manuscript received: October 5, 2001, Initial review
completed: December 31, 2001, Abstract: To evaluate the skills of health workers in assessing the severity of illness among young infants. Design: Cross sectional. Setting: Five different health institutions viz, subcenter, primary health center, community health center, sub-divisional hospital, district hospital. Methods: 110 young infants aged <2months who attended the selected health institutions on specific week days were assessed by a physician. Subsequently 10 female health workers assessed these babies. Physician and health workers used same symptom and sign based guidelines for classification of the illness. Level of agreement between the physician and the health workers were assessed using kappa statistics. Results: Physician classified 37.3% infants as not sick or mildly sick, 42.7% as moderately sick and 20% as severely sick. In comparison to the physician, the sensitivity and specificity of the health workers’ assessment of severe illness was 77% and 76% respectively. Of 22 babies classified as severely sick by the physician, female health workers classified 5 as not sick or mildly sick, 8 as moderately sick and 9 as severely sick. On the other hand health workers classified one not sick or mildly sick and 9 moderately sick infants as severely sick. Level of agreement between the physician and health workers was poor (Kappa value = 0.39, 95% CI = 0.26, 0.52). Health workers misclassified illness mainly due to ‘not counting the respiratory rate and ‘not looking for chest retractions, purulent discharge and jaundice’. Conclusion: Trained health workers’ skills were not satisfactory for assessment of illness severity among young infants. During training, importance of these signs needs to be emphasized. Key words: Evaluation, Infants, Illness, Primary care workers, Skills. World Health Organization estimates that approximately 5 million young infants die worldwide each year, and 98 per cent of these deaths occur in developing countries(1). Infant mortality rate has declined in India mainly because of a decrease in post-neonatal deaths. In 1998, infant and neonatal mortality rate stood at 71 and 47 per 1000 live births respectively(2). The proportion of infant deaths in the neonatal period has increased from half to two-third(3). Prompt and adequate management of illnesses can improve neonatal survival(4). Standard advice is to admit all sick neonates to hospital(5). Due to constraints at family and health center level adherence to referral advice continues to be low. Therefore, to strengthen home-based neonatal care, Child Survival and Safe Motherhood (CSSM) and Reproductive and Child Health (RCH) programs have imparted knowledge and skills to female health workers for diagnosis, management and referral of sick infants(6). Whether health workers have acquired necessary skills for classification of severity of illness among young infants is not known. Therefore, this study was carried out to assess the skills of female primary health care workers for classifying severity of illness among young infants. Subjects and Methods Selection of study sites The study was conducted in five health institutions of erstwhile Ambala district of Haryana from July ’99 to April 2000. These institutions were selected purposively as transport for visiting these areas was available from Department of Community Medicine. All female health workers working in the sampled institutions were included in the study; 1 from District Hospital, 2 from General Hospital, 2 from Community Health Centers, 2 from Primary Health Centers and 3 from Sub-centers. These health workers had undergone training for Multi Purpose Health Worker course after matriculation. Sample size On the basis of a study carried out in Himachal Pradesh(7) it was assumed that 30% of health workers would correctly elicit the signs and symptoms. For a precision of 5%, alpha error of 0.05 and power of 80%, a sample size of 110 babies was considered to be sufficient for the study. Infant enrollment All young infants up to 8 weeks of age who attended OPDs of the selected health institutions for any illness on specific weekdays were eligible for inclusion in the study. Enrolment continued consecutively until 110 babies were available. Those who attended OPDs for follow-up of the same disease or immunization or required resuscitation measures were excluded. A total of 36 young infants were enrolled at District Hospital, 27 at General Hospital, 19 at Community Health Centers, 14 at Primary Health Center, and 14 were included from Sub-centers. Each health worker assessed at least 10 young infants. Consent was taken from the mother before enrolling the babies. Study tool Based on the CSSM(8) and RCH(9) training modules, guidelines for classification of a sick neonate were developed. The guidelines are based on fifteen clinical symptoms and signs. Each symptom/sign has been classified at three levels according to the severity. A baby having any sign and symptom in the third level was classified as severely sick, those having symptom/sign at second level were classified as moderately sick and in the absence of any specific symptom/sign or having symptom/sign at first level the infant was classified as not sick or mildly sick. Infants classified as mildly sick or not sick require no active intervention at health center, whereas moderately sick infants need active management at health center, and severely sick infants need hospitalization. The classification criteria are based on established literature(10) and were endorsed by a group of pediatricians at our institute. Both health workers and physician used these guidelines independently to classify severity of illness among young infants. The physician was trained for using the guidelines in the Pediatrics Department. This study was initiated when high level of agreement was achieved between the physician and pediatrician (Kappa 0.90). Statistical analysis The assessment of female health worker was compared with the physician. Physicians’ classification of sickness was used as gold standard. Sensitivity, specificity and positive predictive value of each abnormal sign and symptom were evaluated. Sensitivity is defined as the proportion of sick young infants correctly classified by the health workers. Specificity, on the other hand, is the proportion of young infants without sickness who were correctly classified by the health workers. The level of agreement between the physician’s and the health worker’s assessment was calculated using ‘Kappa’ statistics(11). Results Profile of health workers Most of the health workers (50%) were in the age group of 30-34 years (mean age 30.4 years, range 27 to 52 years). Their service experience varied from 2 to 28 years (mean 11.2 years). All of them had received training during their service period under Acute Respiratory Infection Control Program, Diarrheal Disease Control Program, Child Survival and Safe Motherhood Program, and Reproductive and Child Health Program. Five health workers reported that during training beside theory lectures they were also shown cases. Profile of infants Out of the 110 young infants studied, 70 (63.6%) were males. Their age varied from 1 to 60 days with an average of 38.5 days. Most of the babies (32%) were in the age group of 50-60 days. Various reasons for coming to clinics were: fever, excessive cry, loose motion, and cough (12.7% each). Median duration of illness was 7.5 days. Physician considered 27.3% of the babies as normal and others as sick. Most common diagnosis was sepsis (12%), followed by pneumonia (11%), URI (10%) and diarrhea (10%). Among babies aged 7 days or less, commonest diagnosis was jaundice (60%). Level of agreement between health worker and physician Table 1 shows the distribution of young infants according to severity of illness classified by the physician and the female health workers. The agreement between physicians’ and health workers’ classification was not satisfactory (Kappa value = 0.39, 95% CI = 0.26, 0.52). Health workers misclassified 23% of the moderately sick babies and 23% of the severely sick babies as not sick or midly sick. The signs that were commonly missed by the health workers among moderately sick babies were jaundice, chest retractions and purulent discharge (Table II). Whereas most health workers could correctly identify some signs and symptoms signifying severe illness, i.e., feeding abnormalities and reduced spontaneous activity. However, their ability to identify other subjective symptoms like type of cry and temperature was low. When the presence of any one abnormal sign and symptom at third level (severe illness) was taken as the criteria for referral, the sensitivity of health workers was 77% whereas the specificity was 76%. Table I Level of Agreement Between Health Worker and Physician for Assessment of Severity of Illness among Young Infants (0-2 months)
Kappa value = 0.39 (95% CI = 0.26, 0.52) Table II Health Workers’ Ability to Identify Signs and Symptoms in Young Infants (0-2 months)
Discussion Guidelines based on signs and symptoms have been developed for classifying illness by the health workers(12-16). Primary aim of these guidelines is to classify the cases into those who can be managed at home or health center and those who need referral or admission. The skills of health workers in using these guidelines have been evaluated among children aged two months to five years(11-15), immediately after the training. These studies show that health workers are capable of correctly categorizing sickness among children belonging to 2 months to 5 years of age group. However, how well a health worker performs while assessing illness among young infant during routine duties in the health care system has not been evaluated before because of the difficulties associated with observation of skills on site in the peripheral clinics where health workers are posted. In the present study, health workers misclassified 23% of the moderately sick babies and 23% of the severely sick babies as not sick or mildly sick. Out of the 22 severely sick young infants, 5 were classified as not sick or mildly sick and 8 as moderately sick. The signs missed by the health workers were level of jaundice, respiratory rate, chest retractions and purulent discharge. Health workers had missed jaundice in 3 out of 4 cases, and chest retractions in 7 out of 8 cases. They did not mention discharge as purulent in 5 out of 6 cases. These errors occurred for several reasons. Most of the health workers (90%) did not count respiratory rate themselves and relied on the history obtained from the mother. None of them had specifically looked for chest retractions; or the assessment of the temperature instability, they felt temperature at the forehead only. Two of the health workers assessed temperature of the abdomen but none felt it over the feet. On the other hand health workers wrongly classified one not sick or mildly sick and nine moderately sick babies as severely sick due to wrong assessment of subjective symptoms like feeding abnormalities. When the presence of any one abnormal sign and symptom at third level (severe illness) was taken as the criteria for referral, the sensitivity of health workers was 77% whereas the specificity was 76%. In studies from Kenya, Gambia, Bangladesh, Uganda, Euthiopia and India, referral rate ranged from 7% to 53%(17). Skills of the health workers should be such that they correctly identify sick cases, i.e., should have high sensitivity. However, to reduce the number of unnecessary referrals, the specificity should not be too low. To obtain optimum results, a balance has to be struck between the sensitivity and specificity. The sensitivity is given more weightage than specificity because a child is likely to suffer more from the omission of treatment that should have been given than from the provision of treatment that was not required. The overall agreement between health workers’ and physician’s assessment was not satisfactory. Health workers are likely to demonstrate their best skills when evaluated. Therefore, this study presents upper limit of the acquired skills. In routine duties their performance may be even less than that observed in this study. More evaluation studies are required on larger number of health workers in various community settings to generalize the findings of this study. As after the training improvement in the performance of health workers in the identification of sick children aged 2 months to 5 years has been shown in many studies(12-16), it may be possible to train health workers for home based newborn care also using a suitable training design. Contributors: SB conceived the idea, collected and analysed data and drafted manuscript. RK provided overall frame work and concept, helped in final interpretation of results and drafting of paper. He will act as the guarantor of the article. SS helped in developing the guidelines for classification of illness, trained the physician involved in the study and helped in drafting of the paper. AA coordinated the study, helped in analysis and interpretation of data and drafting of manuscript. Funding: None. Competing interests : None stated.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
