The evaluation of the skills for the comprehensive care of children under five years of age was carried out by observing the care provided by professionals to 259 children and under five years old, 84.4 per cent (229/259) children between 2 months and 5 years of age, the remaining 11.6 per cent (30/259) children between 0 and 2 months. 95.4 per cent (247/259) of the children assessed were in urban areas. 51.4% (133/259) were cared for in Public Health Service Providers Institutions (HPIs) compared to 48.6% (126/259) in private HPIs.
By level of care, 72.6% (188/259) were assessed at the first level, 16.6% (43/259) at the second level, and 10.8% (28/259) at the third level. Seventy per cent of the children were assessed in the outpatient service, 8.9% in the emergency department and for the remaining 20.5% the care service was not specified (Table 1).
Table 1
Characteristics of IMCI care attention
Evaluated by general medicine, nursing, and pediatrics | 0 to 2 months | 2 months to 5 years | |
| 30 (11.6%) | 229 (84.4%) | |
Attention area | Urban areas | Rural zones | |
| 247 (95.4%) | 12 (4.6%) | |
Health providing institutions | State HPI* | Private HPI | |
| 133 (51.4%) | 126 (48.6%) | |
Level of attention | First level | Second level | Third level |
| 188 (72.6%) | 43 (16.6%) | 28 (10.8%) |
Service | Outpatient Service | Emergency | Not specified |
| 183 (70.6%) | 23 (8.9%) | 53 (20.5%) |
* Health Provider Institutions |
Results: 0 to 2 Months
• Basic registration
The health professionals evaluated fully recorded the basic data on the reason for the consultation, the child's age, and the pathological history, and took appropriate height and weight. Concerning the vital sign’s registry and cephalic perimeter, the temperature is the least evaluated sign in the two-month-old boys/girls evaluated, and the cephalic perimeter was evaluated in 98.9% of the cases. The results by professional profile show that 100% complete registration of basic data, the reason for consultation, age of the child, and pathological history.
• Danger signs
The profile that most evaluated signs of local infection and serious disease is the general physicians; followed by nurses and pediatricians (92%, 82.58%, 59.39%, respectively).
The danger sign that was most evaluated by doctors, nurses, and pediatricians was purulent discharge from the navel, eyes, or ears (93.30%), followed by the presence of vomiting or difficulty breathing (92.03% each). The danger signs that were least evaluated were: the presence of seizures (46.23%) and the sensation of cold or heat in children (50.30%).
• Acute diarrheal disease
In 90.3% of the cases evaluated, health professionals asked the mother or caregiver if she/he had diarrhea. Only 0.4% asked about the duration of diarrhea.
• Growth and feeding practices
All the professionals inquired about whether the baby is fed with breast milk and determined its weight and height. The greatest gap occurred in the investigation for exclusive breastfeeding and the breastfeeding evaluation with 61.6% and 79.3%, respectively.
100% of the two-month-old boys/girls rated by the nurse were evaluated for growth and feeding; followed by the general physician with the evaluation of these aspects in more than 85% of the cases.
• Development
In 99.6% of cases, the mother or caregiver was asked how long the pregnancy lasted and how the delivery was. More than 35% of health professionals did not assess the cephalic perimeter, with pediatricians who omitted most the measurement.
• Vaccination
In 96.7% of the cases, health professionals did not verify a vaccination history for age. Pediatricians only did it in 0.8% and general physicians in 7.4%.
• Abuse
In general, physical abuse, sexual abuse, neglect, and abandonment are under verification. Non-compliance is higher than 44%, and pediatricians are the ones who investigate the least for this cause, with a scarce 26%.
• Competence to Classify
Following the framework of the IMCI strategy, the results of classification of signs of very serious illness, diarrhea, growth, development, and possibility of abuse, in general, professionals correctly classify the mentioned aspects in about 98% of the children evaluated, being the nurses who fulfill in 100% of the cases as included in the table of IMCI procedures.
Results: 2 months to 5 years
• Basic registration
The health professionals evaluated fully recorded the basic data on the reason for consultation, the child's age, and pathological history, and took an adequate measurement of height and weight in more than 85% of the cases.
Regarding the vital sign’s registry and cephalic perimeter, around 40% of the evaluated professionals did not assess or record these data. Pediatricians have the best results in vital signs and cephalic perimeter (Table 2)
Table 2
Percentage of basic registration by general physicians, nurses, and pediatricians
| Nurses % (N = 42) | General Physicians % (N = 107) | Pediatricians % (N = 40) |
Reason for consultation | 100 | 100 | 100 |
Child's age | 100 | 100 | 100 |
Pathological history | 73.9 | 90.9 | 83.3 |
Adequate weight technique | 86.6 | 96.4 | 98.3 |
Appropriate Size Technique | 86.8 | 94.5 | 98.3 |
Temperature | 41.0 | 70.4 | 55.1 |
Heart rate | 50.2 | 54.4 | 82.5 |
Breathing frequency | 63.6 | 59.9 | 79.0 |
Cephalic Perimeter | 74.7 | 68.0 | 96.0 |
• Danger signs
Of the patients evaluated, a complete evaluation of danger signs was performed in less than 60%, with the sign with the lowest evaluation being the presence or not of seizures (43.6%), followed by the evaluation of consciousness (51.6%).
According to the profile of the professional, the values observed by pediatrics are higher, and do not exceed 70% in each sign. For the profile of nurse and general physician the results are similar by sign, without exceeding 65%. This, except for the "vomits all" sign, which is evaluated by a general physician in 76.6% of the children assessed.
• Acute diarrheal disease
84.3% of the health professionals asked the mother or caregiver if the child had diarrhea. In the results of the evaluation of patients with diarrhea, in general, there was high compliance in the evaluation of their characteristics, except in relation to the presence of blood in the stool.
• Febrile syndrome
Of the total number of children assessed, in 89.9% of the cases the mother, or caregiver, was asked if the child had developed a fever. Low compliance is observed in both, identifying a history of displacement to areas with dengue or malaria transmission as well as the evaluation of nuchal stiffness. According to the professional profile of general physicians and pediatricians, 100% compliance was observed in the evaluation of the duration of the fever, as well as less compliance in the evaluation of the history of visits to sites with Vector-Borne Diseases (VTE) and neck stiffness.
• Otalgia
In more than 98% of the cases, the mother or caregiver was asked if the child had ear pain. Of the total number of children assessed, 4.9% had an earache and high compliance (98.5%) with otoscopy and behind-the-ear palpation. By professional profile, the best compliance in the evaluation of this aspect was observed in pediatrician followed by general physicians
• Odynophagia
In 78.2% of the cases, the mother or caregiver was asked if the child had developed odynophagia. In the results of the evaluation of children with odynophagia, high compliance was observed in the evaluation of tonsils and palpation of the neck in 98.5% of the cases. By professional profile, it was observed compliance of 100%, 99.6%, and 62% in the pediatric, general physicians, and nursing profiles, respectively.
• Normal Growth
Concerning the growth evaluation, the growth curves of nutritional indicators were verified: weight for height, weight and height for age, and body mass index, as well as the identification of signs of wasting. Compliance was found to be close to 75% in these criteria. The result of the growth evaluation shows that the pediatrician performs, in more than 90% of the children evaluated, the assessment of nutritional indicators and in 85.6% the identification of signs of wasting.
In the general physician’s profile, the evaluation of growth, in the parameters included in this evaluation, did not exceed 80%. In 57.5% of the cases, the nurses performed the identification of these signs. Regarding the assessment of anemia, low compliance was observed in relation to whether the mother or caregiver was asked if the child had received iron in the last 6 months (37%).
• Development
About development (verification in the development table and determination of the cephalic perimeter), compliance of 65% was generally observed for each of these parameters.
According to the professional profile, the highest compliance was observed in the pediatrician profile; compliance with the profile of general practitioner and nurse is similar.
• Vaccination
In 92.6% of the children evaluated, the health professionals requested the card to verify the vaccination status; In contrast, in less than 30% of the cases, the mother was told that the minor required a vaccine and when to return for its application according to the age schedule. By professional profile, the highest compliance was observed in the evaluation parameter of the vaccination scheme by verification of the card in the nursing profile. In the same way, In the profile of the physician and the pediatrician, a high degree of compliance was evidenced regarding this parameter (Table 3).
Table 3
Percentage of evaluation of topics regarding vaccination
| Nurses % (N = 42) | General Physicians % (N = 107) | Pediatricians % (N = 40) |
Ask for the vaccination card and check the vaccination status | 100 | 86.2 | 95.9 |
Indicates to the mother that the child requires a vaccination | 19.2 | 0.6 | 12.9 |
Indicates to the mother on what date she should bring the child back for the next vaccination | 31.5 | 20 | 14 |
• Malignancy
In general, high compliance was observed in 6 of the 11 parameters evaluated. In the other 4 parameters (inquire for headache and bone pain, loss of appetite, fatigue, and the evaluation of lymph nodes and neurological symptoms), compliance with less than 10% of the children evaluated was observed. Eight of the eleven parameters were evaluated by 100% of the pediatricians, while the general practitioner and nurse show less compliance (Table 4).
Table 4
Malignancy Screening Percentage
| Nurses % (N = 42) | General Physicians % (N = 107) | Pediatricians % (N = 40) |
Ask about fever / sweating for more than 7 days | 98.8 | 39.2 | 10.9 |
Ask about a headache that has been increasing, if you wake up at night, if it is accompanied by vomiting | 0 | 28.6 | 47.9 |
Ask about bone pain in the last month | 0 | 4.3 | 47.9 |
Ask about loss of appetite, weight, or fatigue in the past 3 months | 2.3 | 67.2 | 100 |
Evaluate the child's skin | 99.4 | 95,7 | 100 |
Watch the eyes | 99.4 | 60 | 100 |
Evaluate the nodes | 2.3 | 60 | 100 |
Evaluates focal, acute, or progressive neurological signs and symptoms | 2.3 | 35.7 | 100 |
Ask about vision disturbance | 95.9 | 24..3 | 100 |
Palpate the abdomen | 99.4 | 91.8 | 100 |
Scan the body to identify possible masses | 99.4 | 95.7 | 100 |
• Tuberculosis and HIV
This evaluation was carried out in less than 20% of the children evaluated, being the lowest tuberculosis investigation, only carried out in less than 1% of the cases. Pediatricians were the ones who most met these evaluation criteria, while in no case did the nurse.
• Classify Competition
In general, the classification of signs of very serious illness and the main prevalent illnesses (cough, diarrhea, fever, and ear problems) is done correctly in more than 60% of cases. The possibility of abuse, development, and nutritional status were correctly classified in more than 70% of the children evaluated; breastfeeding, hearing, and anemia problems were correctly assessed in less than 50% of the cases.
• Competence Treat
The definition of appropriate treatment was made as included and indicated in the IMCI procedure chart. The treatment was only evaluated in the pediatrician and general practitioner profiles. Concerning the management of diarrhea and sore throat, 100% of the children classified correctly received adequate management. For fever, 59.5% of the cases classified correctly were managed. In general, it was observed that health professionals gave adequate treatment to a higher percentage of children classified correctly (Table 5).
Table 5
Proper Treatment and Correct Classification of signs and Symptoms
| | Proper treatment |
| | Yes | No |
Correct classification Signs Cough and Shortness of breath | Yes (N = 145) | 65 (44.9%) | 80 (55.1%) |
No (N = 52) | 6 (12.2%) | 46 (87.8%) |
Correct classification Signs Diarrhea | Yes (N = 140) | 140 (100%) | 0 (0%) |
No (N = 52) | 24 (46.2%) | 28 (53.8%) |
Correct classification Signs Fever | Yes (N = 147) | 147 (100%) | 0 (0%) |
No (N = 54) | 32 (59.5%) | 22 (40.5%) |
Correct classification Throat problem | Yes (N = 152) | 152 (100%) | 0 (0%) |
No (N = 71) | 0 | 71 (100%) |