João Joaquim Freitas do Amaral

Improving antimicrobial use among health workers in first-level facilities: results from the Multi-Country Evaluation of the Integrated Management of Childhood Illness strategy

OBJECTIVE The objective of this study was to assess the effect of Integrated Management of Childhood Illness (IMCI) case management training on the use of antimicrobial drugs among health-care workers treating young children at first-level facilities. Antimicrobial drugs are an essential child-survival intervention. Ensuring that children younger than five who need these drugs receive them promptly and correctly can save their lives. Prescribing these drugs only when necessary and ensuring that those who receive them complete the full course can slow the development of antimicrobial resistance. METHODS Data collected through observation-based surveys in randomly selected first-level health facilities in Brazil, Uganda and the United Republic of Tanzania were statistically analysed. The surveys were carried out as part of the multi-country evaluation of IMCI effectiveness, cost and impact (MCE). FINDINGS Results from three MCE sites show that children receiving care from health workers trained in IMCI are significantly more likely to receive correct prescriptions for antimicrobial drugs than those receiving care from workers not trained in IMCI. They are also more likely to receive the first dose of the drug before leaving the health facility, to have their caregiver advised how to administer the drug, and to have caregivers who are able to describe correctly how to give the drug at home as they leave the health facility. CONCLUSIONS IMCI case management training is an effective intervention to improve the rational use of antimicrobial drugs for sick children visiting first-level health facilities in low-income and middle-income countries.

Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil

A multi-country evaluation is being carried out in Brazil and four other countries to determine the effectiveness, cost, and impact of the Integrated Management of Childhood Illness (IMCI). We examine the effect of IMCI on the quality of health care provided to children under five visiting health facilities. A health facility survey was conducted at 24 facilities (12 with IMCI) in each of four States in the Northeast. We assessed the quality of care provided to children between 2 months and 5 years attending the facilities. Health workers trained in IMCI provided significantly better care than those not trained. Significant differences between health workers who were trained or not trained in IMCI were found in the assessment of the child, disease classification, treatment, and caretaker communication. Nurses trained in IMCI performed as well as, and sometimes better than, medical officers trained in IMCI. We conclude that while there is room for further improvement, IMCI case management training significantly improves health worker performance, and that parts of Brazil that have not yet introduced IMCI should be encouraged to do so.

Are health interventions implemented where they are most needed? District uptake of the Integrated Management of Childhood Illness strategy in Brazil, Peru and the United Republic of Tanzania

OBJECTIVE To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs. METHODS We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years. FINDINGS In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied. CONCLUSION Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

Association between stress and breast cancer in women: a meta-analysis

The objective of the current meta-analysis was to verify the association between stressful life events and primary breast cancer incidence in women. A total of 618 studies from 1982-2007 were found in the PubMed, LILACS, and Cochrane Library databases. Methodological quality was evaluated according to the Downs & Black criteria. Eight studies were selected (six case-controls and two cohorts). The studies were grouped in three analyses, two of which based on the categories widowhood and divorce and the other based on self-rated intensity and frequency of stressful events. Relative risks were: widowhood 1.04 (95%CI: 0.75-1.44; p = 0.800); divorce 1.03 (95%: 0.72-1.48; p = 0.850); and intensity/frequency of stress 1.73 (95%CI: 0.98-3.05; p = 0.059). We conclude that stressful life events as a whole are not associated with risk of breast cancer in women. However, it is not possible to rule out high-intensity stress as a risk factor for breast cancer.

Cost implications of improving the quality of child care using integrated clinical algorithms: evidence from Northeast Brazil.

OBJECTIVES Previous research has shown that providers trained in the Integrated Management of Childhood Illness offered higher quality care for under-fives than those providing routine care in several settings including Northeast Brazil. The objective of this paper is to examine if such quality improvements adds to total costs or is cost saving. METHODS The additional costs associated with treating children based on IMCI clinical algorithms in northeast Brazil are estimated by comparing the total costs of under-five care in 22 municipalities with IMCI with 22 matched municipalities providing routine care. Multivariate analysis was also used to isolate the effect of IMCI on costs at primary facilities, controlling for other possible determinants. RESULTS For 2001, there was no statistically significant difference in the cost per child of caring for under-fives in IMCI municipalities (US

Integrated Management of Childhood Illness: efficiency of primary health in Northeast Brazil

95) relative to the comparison municipalities (US

The effect of training in Integrated Management of Childhood Illness (IMCI) on the performance and healthcare quality of pediatric healthcare workers: a systematic review

98). Moreover, IMCI training had no independent effect on unit costs at primary facilities, the largest component in overall costs per child (79%). Case load was the most important determinant. CONCLUSION Our findings suggest that scaling up IMCI-based care could increase child health outcomes in Brazil without increasing overall health costs.

Implementação da estratégia Atenção Integrada às Doenças Prevalentes na Infância no Nordeste, Brasil

OBJECTIVE The Integrated Management of Childhood Illness is a strategy designed to address major causes of child mortality. The aim of this study was to assess the impact of the strategy on the quality of child health care provided at primary facilities. METHODS Child health quality of care and costs were compared in four states in Northeastern Brazil, in 2001. There were studied 48 health facilities considered to have had stable strategy implementation at least two years before the start of study, with 48 matched comparison facilities in the same states. A single measure of correct management of sick children was used to assess care provided to all sick children. Costs included all resources at the national, state, local and facility levels associated with child health care. RESULTS Facilities providing strategy-based care had significantly better management of sick children at no additional cost to municipalities relative to the comparison municipalities. At strategy facilities 72% of children were correctly managed compared with 56% in comparison facilities (p=0.001). The cost per child managed correctly was US

Adaptação e aplicabilidade do componente "maus-tratos" à estratégia da Atenção Integrada às Doenças Prevalentes na Infância no Brasil

13.20 versus US

Implementation of the Integrated Management of Childhood Illnesses strategy in Northeastern Brazil

21.05 in the strategy and comparison municipalities, respectively, after standardization for population size. CONCLUSIONS The strategy improves the efficiency of primary facilities in Northeastern Brazil. It leads to better health outcomes at no extra cost.OBJECTIVE: The Integrated Management of Childhood Illness is a strategy designed to address major causes of child mortality. The aim of this study was to assess the impact of the strategy on the quality of child health care provided at primary facilities. METHODS: Child health quality of care and costs were compared in four states in Northeastern Brazil, in 2001. There were studied 48 health facilities considered to have had stable strategy implementation at least two years before the start of study, with 48 matched comparison facilities in the same states. A single measure of correct management of sick children was used to assess care provided to all sick children. Costs included all resources at the national, state, local and facility levels associated with child health care. RESULTS: Facilities providing strategy-based care had signifi cantly better management of sick children at no additional cost to municipalities relative to the comparison municipalities. At strategy facilities 72% of children were correctly managed compared with 56% in comparison facilities (p=0.001). The cost per child managed correctly was US