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ORIGINAL ARTICLE
Year : 2011  |  Volume : 55  |  Issue : 4  |  Page : 298-302  

Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training


1 Junior Resident, Post Graduate Institute of Medical Education and Research, India
2 Senior Resident, Post Graduate Institute of Medical Education and Research, India
3 Assistant Professor, Post Graduate Institute of Medical Education and Research, India
4 Professor, School of Public Health, Post Graduate Institute of Medical Education and Research, India

Date of Web Publication30-Jan-2012

Correspondence Address:
Arun Kumar Aggarwal
Professor, School of Public Health, Post Graduate Institute of Medical Education and Research
India
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Source of Support: National Rural Health Mission, Conflict of Interest: None


DOI: 10.4103/0019-557X.92410

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   Abstract 

Background: The primary health care workers of a district in northern India were trained in the year 2006 for Integrated Management of Neonatal and Childhood Illness (IMNCI) using two different training methods: conventional 8-day training and new interrupted 5-day training. Knowledge and skills may decline over a period of time. Rate of decline may be associated with the type of training. A study was thus conducted to see the retention of knowledge and skills in the two training groups, 3 years after the initial training. Materials and Methods: This study was done in the Panchkula district of Haryana state in northern India. In the year 2006, 50 primary health care workers were given new interrupted 5-day training and another 35 workers were given conventional 8-day training on IMNCI. Knowledge and skills of the same workers were evaluated in the year 2009, using the same methodology and tools as were used in the year 2006. Data analysis was done to see the extent of decline in knowledge and skills in these 3 years and whether decline was more in any particular training group. Results: Compared to post-training score in the year 2006, composite knowledge and skill scores for Auxilliary Nurse Midwives (ANMs) and Anganwari workers (AWWs) together declined significantly in the year 2009 from 74.6 to 58.0 in 8-day training group and from 73.2 to 57.0 in 5-day training group (P < 0.001). Follow-up composite scores in the two training groups were similar. Whereas the decline was more for knowledge scores in 8-day training group and for skill score in 5-day training group, the pattern of decline was inconsistent for different health conditions and among ANMs and AWWs. Conclusion: Long-term retention of knowledge and skills in 5-day group was equivalent to that in 8-day training group. Refresher trainings may boost up the decline in the knowledge and skills.

Keywords: Anemia, Breastfeeding, Counseling, Malnutrition, Neonate, Training


How to cite this article:
Venkatachalam J, Kumar D, Gupta M, Aggarwal AK. Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training. Indian J Public Health 2011;55:298-302

How to cite this URL:
Venkatachalam J, Kumar D, Gupta M, Aggarwal AK. Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training. Indian J Public Health [serial online] 2011 [cited 2019 Aug 22];55:298-302. Available from: http://www.ijph.in/text.asp?2011/55/4/298/92410


   Introduction Top


Integrated Management of Childhood Illness (IMCI) strategy was developed to address the limitations of disease-specific child health programs. [1],[2] In the year 2000, the Government of India included neonatal component in this and rechristened the strategy as Integrated Management of Neonatal and Childhood Illness (IMNCI). [3] It envisaged training of primary care workers and medical officers in identification, management and referral of neonatal and childhood illness. Training is for a duration of 8 days, is resource intensive and has many operational difficulties. [4],[5] Thus, a new interrupted 5-day training program was developed and delivered in northern India. [4] The results showed equivalent rise in score among the participants who received standard 8-day and those who received new interrupted 5-day training.

Knowledge and skill may decline over a period of time [5] differentially in the two training groups, with more decline after 5-day training than after 8-day training. It may be argued that immediately after the training, both training groups could have similar scores, but retention of knowledge and skill can be more among those who receive training for a longer duration. However, there is no evidence showing such association. The present study was thus conducted to assess the status of knowledge and skills score in the two training groups after 3 years of their initial training to document the overall decline and also to examine whether decline occurred more in any particular training group.


   Materials and Methods Top


This was a follow-up cohort study and was carried out in the Panchkula district of Haryana state in northern India. In the year 2006, Auxilliary Nurse Midwives (ANMs) and Anganwari workers (AWWs) were invited in two groups. Conventional 8-day training was given to one group and new interrupted 5-day training to the other group. Each group had a mix of ANMs and AWWs. A follow-up evaluation of knowledge and skills of the same participants was done using the same assessment tools and methods as were used in the initial assessment and have been described elsewhere. [4] In brief, for knowledge assessment, multiple choice questionnaire was administered, which carried a maximum score of 28. It had questions to test knowledge about anemia, breastfeeding, diarrhea, immunization, malnutrition, malaria, meningitis, and possible severe bacterial infection.

For skills, the participants were assessed for counting respiratory rate, detecting chest in-drawing, looking for dehydration, assessment of breastfeeding technique, and counseling. Video case demonstration, role play and dummy client examinations were used for skill assessment. Skill observation checklists carried a total score of 26 in the above domains. In addition, the same clinical problem-based questionnaire with a maximum score of 30 was used to assess the skills of consulting the modules and treatment charts for taking decisions about various disease conditions as used during 8-day and 5-day training.

Data analysis was done by using Epi Info 2000 computer software. Since the maximum scores for knowledge (28), skill assessment by clinical problem-based questionnaire (30) and skill assessment through observation checklist (26) were different, the score of each participant for each of the knowledge and skill assessment methods was converted to a relative scale having a maximum score of 100. Questionnaire and scoring system followed was the same as used in the earlier study. [4] For example, if the score of a participant was 10 out of a maximum score of 28, then the score of the participant on a common scale having a maximum score of 100 would be 35.7 [(10/28) × 100]. Unpaired t-test was used to look for statistically significant change in the follow-up score compared to the post-test score after both types of trainings given in the year 2006. Subgroup analysis was done for hypothesis generation to see the differentials in knowledge and skill scores for different health conditions separately for ANMs and AWWs in the two training groups. As the sample size got very less in these subgroups, nonparametric (Mann-Whitney U) test was used for assessing change in knowledge and skill score for different disease conditions among the ANMs and AWWs separately.

Ethical justification

The protocol was approved by the institute ethics committee and permission was also sought from the State Health Services of Haryana.


   Results Top


In the year 2006, a total of 46 ANMs and 39 AWWs were trained in four batches. The same ANMs and AWWs in the same four batches were called for follow-up evaluation in the year 2009. Totally 36 (78.2%) ANMs and 37 (94.9%) AWWs participated in the follow-up study. Twelve (14.0%) workers could not participate. The socio-demographic characteristics of the follow-up participants were statistically similar to the participants of the year 2006.

Follow-up knowledge and skill scores were compared with the post-training scores of the year 2006, separately for 8-day training group and new interrupted 5-day training group. Composite knowledge and skill scores of both categories of workers (ANMs and AWWs) declined significantly from 74.6 to 58.0 in 8-day training group and from 73.2 to 57.0 in 5-day training group. Decline occurred in both knowledge and skills score separately. Whereas the average knowledge score declined from 81.6 to 65.5 in 8-day training group and from 74.6 to 66.3 in 5-day training group (P < 0.001), the skill scores also decreased significantly (P < 0.001) from 73.1 to 54.1 and from 90.4 to 53.1 in the two training groups, respectively.

Further, 95% Confidence Interval for composite knowledge and skill scores revealed that decline in both the training groups was comparable; however, the decline was more for knowledge scores in 8-day training group and for skill score in 5-day training group [Table 1]. Further, subgroup analysis with category of workers showed that ANMs in 8-day training group had shown marginally higher decline in composite knowledge and skill scores than those in 5-day training group. AWWs of both training groups demonstrated similar decline.
Table 1: Knowledge and skill scores post-training in the year 2006 and at follow-up in the year 2009, training group wise

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Health condition wise analysis showed, surprisingly, increase in the knowledge score for anemia in the 5-day group, with no significant differential among ANMs and AWWs. For other health conditions like breastfeeding, malnutrition, diarrhea, malaria and meningitis, the decline was significant in the 8-day group; with ANMs showing significant decline for breastfeeding and meningitis; but for diarrhea and malnutrition scores, the decline was not significantly different among ANMs and AWWs. Malaria scores of AWWs also declined [Table 2].
Table 2: Knowledge and skill scores post-training in the year 2006 and at follow-up in the year 2009, health condition wise among ANMs and AWWs

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Significant decline in skill score occurred in both the training groups for respiratory and diarrhea assessment, with follow-up scores in the two training groups not significantly different for respiratory assessment. AWWs in both the groups and ANMs in the 8-day group showed a significant decline in respiratory assessment scores. For diarrhea assessment, ANMs and AWWs of both the groups showed a significant decline. On breastfeeding assessment, the decline was significant in 5-day group. However, no differential in decline in the two training groups was noticed among ANMs and AWWs. With counseling skills, the decline was significant in 8-day group, with ANMS showing greater decline. However, follow-up scores in both the groups were not significantly different [Table 2].


   Discussion Top


In a previous study, new interrupted 5-day training package was compared with conventional training package of 8-day duration and was found to be cost effective. [4] However, there was no evidence about long-term retention of knowledge and skills using different training methods of different durations. Current study was done to explore this differential in the retention of knowledge and skills in the two training groups, 3 years after the initial training.

We found that after 3 years of initial training, the composite score for knowledge and skills dropped significantly in both the 8-day and 5-day training groups, with more decline occurring in knowledge score in the 8-day group and in skill score in the 5-day group. Decline in the knowledge and skill score was inconsistent for ANMs and AWWs. We found that end line scores were comparable for both ANMs and AWWs in both the training groups.

It may be argued that skill retention was not better after 5-day training. However, we found inconsistent pattern of decline for different skills. Whereas significant decline occurred in both the groups for respiratory assessment and diarrhea assessment, follow-up skill scores were similar for the former. Similarly, decline was more for breastfeeding skills and less for the counseling skills in the 5-day group; however, follow-up scores were similar in the two groups for the later. In knowledge assessment, the 5-day training group performed better in almost all the knowledge domains.

Decline in knowledge was much less in the present study compared to that reported in another study conducted in rural Haryana, where the knowledge score of primary care workers on disease and their management declined up to 50 points after 1 year follow-up. [6] In other studies from India, the decline was up to 10 points after 6 months [7] and 33 points after 1 year of follow-up. [8] Another Indian study showed that majority of the workers do acquire skills of counting respiratory rate, assessment of breastfeeding and malnutrition; however, the skills for feeding advice were poor. [9]

Retention of knowledge and skills may also depend on the follow-up supervisory visits and the interest of the health systems in implementation of IMNCI. In the present study, as all these workers belong to the same district, no such differentials existed for the two training groups. Moreover, since the training of the workers 3 years back, the district has not initiated supervisory visits and the efforts for implementation are still in infancy. Therefore, no factor other than the training could have influenced the results.

Our study has many strengths. Firstly, this is one of the few studies that have captured long-term retention of knowledge and skills in the same group of participants who were trained by using two different training methods. Secondly, we used standardized methodology and tools for evaluation that were used before. Thirdly, loss to follow-up of participants even after 3 years in a government set-up with frequent transfers was very less. However, some limitations of the study are also worth mentioning. Findings of subgroup analysis need to be interpreted with caution as this was done to understand the differentials for further hypothesis generation. Sample size was not sufficient for these subgroups.


   Conclusion Top


Three years after IMNCI training, there was significant decline in the knowledge and skill scores in the both training groups of new interrupted 5-day training and conventional 8-day training. However, there is no evidence showing consistently greater decline in the 5-day training group. Thus, it is evident from our study that training uptake and retention was equivalent in both the training groups. The 5-day training had either equivalent decline or even outperformed 8-day training for most of the knowledge and skill domains.

It has important policy implications. Considering the problems that the countries are facing in training the huge workforce in limited time, it is worth that this 5-day training package be tried in other regions to test its replicability, and after suitable adoptions and modifications, it be accepted as the standard training package for primary care workers and AWWs. Further, to boost up the knowledge and skills, 1-day refresher package may be devised and tested and workers may be given periodic refresher trainings. However, further operations research would be required to determine the periodicity of such trainings.


   Acknowledgments Top


We would like to thank the Director General of Health Services Haryana, and Nodal Officer, National Rural Health Mission, Haryana, for providing the budget and support to the Civil Surgeon, Panchkula, Haryana, for deputing the ANMs and to the Project Director, Integrated Child Development Scheme, Panchkula, Haryana, for deputing AWWs for the follow-up training.

 
   References Top

1.Tulloch J. Integrated approach to child health in developing countries. Lancet 1999;357 Suppl 2:S1116-20.   Back to cited text no. 1
    
2.Claeson M, Waldman RJ. The evolution of child health programmes in developing countries: From targeting diseases to targeting people. Bull World Health Organ 2000;78:1234-45.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Repository on Maternal and Child Health. Government Guidelines -- Operational guidelines for implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI). Available from: http://202.71.128.172/nihfw/nchrc/index.php?q=content/government-guidelines-operational-guidelines-implementation-integrated-management-neonatal-a. [Last accessed on 2011 Nov 17].   Back to cited text no. 3
    
4.Kumar D, Aggarwal AK, Kumar R. Interrupted 5-day Training on Integrated Management of Neonatal and Childhood Illness (IMNCI): Effect on the knowledge and skills of primary health. Health Policy Plan 2009;24:94-100.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Bryce J, Victoria CG. Ten methodological lessons from the multi-country evaluation of integrated management of childhood illness. Health Policy Plan 2005;20:94-104.  Back to cited text no. 5
    
6.Anand K, Patro BK, Paul E, Kapoor SK. Management of sick children by health workers in Ballabgarh: Lessons for implementation of IMCI in India. J Trop Pediatr 2004;50:41-7.  Back to cited text no. 6
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7.Dwivedi RR, Mishra CP, Singh LS, Tiwari IC. Impact of the training on knowledge of community health guides in some selected areas of primary health care. Indian J Community Med 1989;14:120-3.  Back to cited text no. 7
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8.Chaudhary N, Mohanty PN, Sharma M. Integrated management of childhood illness (IMCI) follow-up of basic health workers. Indian J Pediatr 2005;72:735-9.  Back to cited text no. 8
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9.Biswas AB, Mukhopadhyay DK, Mandal NK, Panja TK, Sinha N, Mitra K. Skill of frontline workers implementing Integrated Management of Neonatal and Childhood Illness (IMNCI): Experiences from a district of West Bengal, India. J Trop Pediatr 2011;57:352-6.  Back to cited text no. 9
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2]


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